
Qass. 
Book. 



COPYRIGHT DEPOSIT 



THE 



DIAGNOSIS 



OF 



DISEASES OF WOMEN. 



A TREATISE FOR STUDENTS AND PRACTITIONERS. 



BY 

PALMEE FINDLEY, B.S., M.D., 

INSTRUC!TOR IN OBSTETRICS AND GYNECOLOGY, RUSH MEDICAL, COLLEGE IN AFFILIATION 

WITH THE UNIVERSITY OF CHICAGO ; ASSISTANT ATTENDING GYNECOLOGIST TO THE 

PRESBYTERIAN HOSPITAL, CHICAGO; FELLOW OF THE AMERICAN 

GYNECOLOGICAL SOCIETY; FELLOW OF THE CHICAGO 

GYNECOLOGICAL SOCIETY. 



SECOND EDITION, REVISED AND ENLARGED. 



ILLUSTRATED WITH 222 ENGRAVINGS IN THE TEXT AND 59 PLATES 
IN COLORS AND MONOCHROME. 




LEA BEOTHEES & CO., 
PHILADELPHIA AND NEW YORK. 

1905. 




LIBRARY of OONGRESS 
Two Copies KecMveo 

APR ii iyu5 

UUiiiS (Z XXc. Noi 
COPY B. 






Entered according to Act of Congress, in the year 1905, by 

LEA BROTHERS & CO., 

in the Office of the Librarian of Congress. All rights reserved. 



DORNAN, PRINTER, 
PHILADELPHIA. 



IN 

FILIAL AFFECTION 
FOR 

DAVID FINDLEY, M. D., 

AND AS A TRIBUTE TO THE ACHIEVEMENTS 
IN OBSTETRICS AND GYNECOLOGY 

OF 

J. CLARENCE WEBSTER, A.M., M.D., F.R.S.E., F.R.C.P., 

THIS BOOK IS 
DEDICATED. 



PREFACE TO THE SECOND EDITION. 



In the comparatively brief period which has sufficed to exhaust 
the first issue of this work there have been no revolutionary devel- 
opments in its subject. There has been, however, a substantial 
growth, and this is represented by an increase of nearly one hun- 
dred pages in the text and by the addition of a large number of 
new and original illustrations and colored plates. Each topic has 
been presented thoroughly to date, and as completely as is desirable 
from the standpoint of practicality. Much has been added upon 
the differential diagnosis of the various diseases of the genito- 
urinary organs. 

The latest developments have been presented in subjects still 
in dispute, especially cystic degeneration of the ovaries, chorio- 
epithelioma malignum, and diseases of the ureters and kidneys. 

New chapters have been added upon Examination of the Blood 
and Bacteriological Examinations, subjects which have a most 
important bearing in Gynecological Diagnosis. 

The author again commits the book to the medical profession 
in the hope that it will continue to render substantial service. 

P. F. 

100 State Street, Chicago, 1905. 



(V) 



PREFACE TO THE FIRST EDITION. 



It has been the endeavor of the author to write a work on the 
Diagnosis of Diseases of Women that will be equally adapted to 
the needs of student and practitioner, and in line with the most 
modern views. The recognition of the pathology of the pelvic 
organs in large measure constitutes a diagnosis. Because of this 
fundamental fact the author has deemed it desirable to incorporate 
a thorough discussion of the morbid anatomy, both macroscopic 
and microscopic, and to point out its clinical indications. Special 
stress has been placed upon the microscopic diagnosis of the various 
lesions, not alone on account of its scientific interest, but also, and 
more particularly, because of its great clinical importance. Without 
the microscope a diagnosis is not always possible. 

Medical literature in the English language has not hitherto 
included a work on this subject. In the effort to supply this 
desideratum the author has aimed to satisfy the requirements of 
those who have felt the need of more comprehensive and prac- 
tical information than can be given in the general text-books on 
gynecology. It is hoped that this work will be serviceable to 
those who do not have access to foreign literature. 

The author desires to express appreciation of the services rendered 
in the writing of the book. Dr. D. P. Johnson gave invaluable 
assistance in the critical reading of the manuscript; Dr. Charles 
G. Farnum in the correction of the proof; Miss Mamie Findley 
and Dr. Carl Wahrer in the production of illustrations. Indebted- 
ness is also acknowledged to Veit's Handhuch jilr Gyiidkologie, 

(vii) 



Viii PREFACE TO FIRST EDITION 

Winter's Gyndkologische Diagnostik, Webster's Ectopic Pregnancy, 
Cullen's Cancer of the Uterus, Kelly's Operative Gynecology, and 
Dudley's Gynecology. The author furthermore desires to express 
appreciation of his very cordial relations with the publishers, 
which have at all times been most gratifying. 

PALMER FINDLEY. 

100 State StreeT; Chicago, 1903. 



CONTENTS. 



PAET I. 

GENERAL DIAGNOSIS. 
CHAPTER I. 

PAGE 

The Clinical History. ..... 17 

A Plea for an Early Diagnosis . . . . . . . . .17 

Form of Case Record . . . . . . . . . .19 

Address 21 

Age 21 

Occupation .......... 22 

Nationality ........... 22 

Social State 22 

Number of Children and Miscarriages ...... 23 

Family History 23 

Previous Illnesses . . . . . . . , . .23 

Present Complaints . . . . . . . . . .24 

Menstrual History ......... 24 

Hemorrhage from the Genital Tract ....... 24 

Menstruation ..... 1 .... 25 

Anatomy of Menstruation . ....... 26 

Menstruating Fallopian Tube . . ...... 28 

Uterine Hemorrhage .......... 29 

Systemic Causes . . . . . . . ... .29 

Local Causes . . . . . . . . . . .30 

Amenorrhoea ............ 36 

General Causes. . . . . . . . . . . 36 

Local Causes ........... 37 

Menstrual Molimina . . .- . . . . . .38 

Dysmenorrhoea . . . . . . . . . . .39 

Idiopathic (Primary) 40 

Secondary 41 

Membranous 42 

Nasal 43 

Sterility in Women 43 

General Causes 45 

Local Causes • • .46 

(ix) 



X CONTENTS 

PAGE 

Menopause ............ 49 

Factors Influencing ...... ... 49 

Premature ........... 50 

Delayed 50 

Influence on Morbid Conditions of Pelvis ...... 52 

Leucorrhcea ............ 53 

Normal Secretions .... ..... 53 

In Infants ........... 53 

In Virgins . . . . . . . . . . .54 

In Period of Sexual Maturity ........ 54 

In Old Women .......... 55 



CHAPTER II. 
Physical Examination 



Preliminary Measures 



56 
56 



CHAPTER III. 

External Abdominal Examination, Inspection of the Abdomen 



59 



CHAPTER IV. 
Palpation of the Abdomen 



60 



CHAPTER V. 
Percussion of the Abdomen 



63 



CHAPTER VI. 
Auscultation and Mensuration of the Abdomen 



64 



CHAPTER VII. 

Examination of the External Genitals 



Digital Examination of the Internal Genitals 
Vagina ..... 
Choice of Hand 
One or Two Fingers Used 
Bimanual Examination 
Abdominovaginal Examination 
Examination under Narcosis 
Digital Examination of the Rectum 
Abdominorectal Examination 
Abdominovaginorectal Examination 
Digital Examination of the Bladder 
Pelvimetry .... 



65 

65 
66 
68 
69 
70 
70 
74 
74 
76 
77 
78 
78 



CHAPTER VIII. 
The Vaginal Speculum 



79 



CONTENTS xi 

CHAPTER IX. 

PAGE 

The Vulsella ... .82 

CHAPTER X. 

Uterine Dilators .... 83 

CHAPTER XI. 

The Uterine Sound .... 84 

Preliminary Measures . . . . . ... . , .84 

Indications ............ 85 

Dangers Involved .87 

CHAPTER XII. 

The Uterine Curette .... 88 

In Diagnosis ............ 88 

Contraindications . . . . . . . . . . .90 

Dangers Involved . . . . . . . . . . .90 

Technique , . . . , 91 

CHAPTER XIII. 
Microscopic Examination of Scrapings and Excised Pieces 93 

Removal of Scrapings .......... 93 

Test Excision from the Cervix ......... 94 

Test Curettage of the Uterus 94 

Frozen Sections .94 

Fixing the Specimens .......... 96 

Hardening and Embedding ......... 97 

Method of Staining and Mounting 99 

Inspection of the Uterus after Removal 100 

CHAPTER XIV. 
Exploratory Punctures and Incisions . . .102 

CHAPTER XV. 
Examination of the Blood . . o .103 

CHAPTER XVI. 
Bacteriological Examinations . . . ,116 



xii CONTENTS 

PAKT 11. 

SPECIAL DIAGNOSIS. 
CHAPTER XVII. 

PAGE 

The Diagnosis of Pregnancy . . . ,125 

First Trimester 125 

I. Subjective Signs . . . . . . . , . 125 

1. Cessation of Menstruation . . . . . . .125 

2. Morning Sickness 127 

3. Salivation . . 127 

4. Nervous Phenomena . . . . . . . .128 

5. Irritable Bladder . 128 

II. Objective Signs 128 

1. Mammary Glands ......... 128 

2. Discoloration of Vulva and Vagina ....... 128 

3. Softening of Cervix 128 

4. Lower Uterine Segment . . . . . . . .130 

5. Leucorrhcea . , , . . . . . . . 130 

6. Changes in Position, Size, Form, and Consistency of the Uterus 131 
Second Trimester ........... 131 

I. Subjective Signs . . . . . . . . . 131 

II. Objective Signs .......... 131 

1. Active FcBtal Movements . . . , . . . 131 

2. Passive Foetal Movements . . . . . . .132 

3. Direct Palpation of the Foetus . . . . . .132 

4. Intermittent Uterine Contractions . . . . . .132 

5. Auscultation . . . . . . . ■ . . . 133 

Fetal Heart Tones 133 

Fetal Souffle 133 

Placental Souffle .• . . .133 

6. Rate of Growth of Uterus ....... 134 

7. Changes in Position, Size, Form, and Consistency of the Uterus 134 
Third Trimester - 134 

I, Subjective Signs . . . . . . . . .134 

II. Objective Signs 134 

Diagnosis of the Life or Death of the Foetus ...... 135 

Diagnosis of the Time of Pregnancy and Prediction of Date of Confinement 136 
Diagnosis of Multiple Pregnancy . . . . . . . .137 

Diagnosis of the Causes of Hemorrhage Occurring during Pregnancy . 137 
Diagnosis of Abortion . . . . . . . . . .139 

Anatomical Diagnosis of Pregnancy . . . . . . . 140 

CHAPTER XVIII. 

The Microscopic Diagnosis of Expelled Membranes from the Uterus 144 
Membranous Dysmenorrhoea , , , . , ♦ , ,145 



CONTENTS xiii 

CHAPTER XIX 

PAGE 

The Diagnosis of Ectopic Pregnancy . . 147 

Etiology 147 

Classification ........ ... 149 

Retrogressive Changes in the Foetus .156 

Anatomical Changes in the Tube . . . . . . . .157 

Clinical Diagnosis ........... 160 

Subjective Signs . . . . . . . . . .160 

Objective Signs . . . . . . . . . 161 

Differential Diagnosis .166 

CHAPTER XX. 

The Diagnosis of Hydatiform Mole . . .173 

Synonyms 173 

History 173 

Etiology 173 

Microscopic Examination . . . . . . . . .177 

Malignant Degeneration . . . . . . . . .182 

Diagnosis 186 

CHAPTER XXI. 

The Diagnosis of Chorioepithelioma Malignum . .192 

Etiology 193 

Diagnosis ............ 193 

Macroscopic Appearance . . . . . . . . .194 

Primary Outside of the Placental Site . . . . . . ,196 

CHAPTER XXII. 

The Diagnosis of Malformations of the Uterus . 203 

Uterus Deficiens , 203 

Uterus Rudimentarius 204 

Uterus Foetahs 204 

Uterus Unicornis . . . . . . . . . . . 206 

Uterus Septus (Bilocularis) 208 

Uterus Bicornis . . . . . . . . . . . 208 

Uterus Didelphys 210 

Uterus Accessorius . . . . . . . . . .210 

CHAPTER XXIII. 

The Diagnosis of Malposition of Uterus and its Neighboring.Organs 212 

Pathological Mobility of the Uterus ........ 215 

Pathological Fixation of the Uterus . . . , . . . .215 

Anteposition ............ 215 



XIV 



CONTENTS 



PAGE 

Retroposition . , . 216 

Lateroposition . . . . . . . . . . . .217 

Elevatio Uteri 219 

Torsion of the Uterus .......... 220 

Prolapsus Uteri . . . . . . . . . . 220 

Inversion of the Uterus .......... 231 

Anteversion of the Uterus ......... 237 

Anteflexion of the Uterus ......... 238 

Retroversio-flexion of the Uterus . . . . . . . , 240 

Hernia of the Uterus (Hysterocele) . 247 



CHAPTER XXIV. 

The Diagnosis of Diseases of the Vulva . . 248 

Anomalies in Development ......... 248 

Vulvitis 250 

Circulatory Disturbances ......... 253 

Hypertrophy ........... 253 

Atrophy (Kraurosis Vulva?) ......... 256 

New-formations ........... 258 

Ulcers 262 

Pruritus Vulvae 263 

Hymen 264 

CHAPTER XXV. 

The Diagnosis of Diseases of the Vagina . . 267 

Maldevelopments and Malformations 267 

Vaginitis (Colpitis) 272 

Paravaginitis ............ 276 

New-formations .......... 277 

CHAPTER XXVI. 



Endometritis 








. 284 


Clinical Classification ..... 








. 285 


1. Acute Endometritis .... 








. 285 


2. Chronic Endometritis 








. 286 


Anatomical Classification 








.290 


I. Macroscopic 








. 290 


11. Microscopic 








. 292 


Diagnosis of Uterine Scrapings in Endometritis 








. 299 


Endocervicitis ........ 








. 299 


Erosions of the Cervix ...... 








. 301 


Ulcers of the Cervix ....... 






. 305 


Tuberculosis of the Cervix ..... 








. 305 



CONTENTS 



XV 



Chionic Metritis 
Abscess of the Uterus 



PAGE 

306 
306 



CHAPTER XXVII. 
The Diagnosis of Fibromyoma of the Uterus . 

Etiology ............ 

Influence of Menstruation, Pregnancy, and Climacteric upon Fibromyo 

mata .... 
Histogenesis 
Anatomical Diagnosis 
Recurrence of Uterine Fibroids 
Microscopic Diagnosis 
Adenofibromyoma Uteri 
Degeneration of Fibroids 

Changes in the Endometrium, Myometrium, Tubes, and Ovaries 
Clinical Characteristics . 
Clinical Diagnosis , 
Differential Diagnosis 
Fibroids Imperil Life 



308 
308 

309 
310 
310 
317 
318 
318 
320 
324 
325 
326 
332 
335 



CHAPTER XXVIII. 



The Diagnosis of Carcinoma of the Uterus 



Topographical Classification 
Etiology .... 
Anatomical Diagnosis 
Clinical Diagnosis 
Microscopic Diagnosis 
Differential Diagnosis 
Diagnosis of Extension . 
Diagnosis of Recurrence . 
Endothelioma , 



340 

340 
340 
342 
347 
353 
360 
366 
368 
369 



CHAPTER XXIX. 
The Diagnosis of Sarcoma of the Uterus 



Etiology . . . 
Anatomical Diagnosis 
Microscopic Diagnosis 
Olinical Diagnosis . 



371 

371 
372 
374 
375 



CHAPTER XXX. . 
The Diagnosis of Diseases of the Tubes 



Methods of Examination 
Anomalies in the Structure 
Changes in the Position 



377 

377 
378 
378 



XVI 



CONTENTS 



Circulatory Disturbances 

Inflamraations and Infections . 
Granulomata 

Classification of Salpingitis 
Catarrhal Salpingitis 
Salpingitis Isthmica Nodosa 
Hydrosalpinx , 
Tubo-ovarian Cyst . 
Hsematosalpinx 
Purulent Salpingitis 
Diagnosis of Sactosalpinx 
Differential Diagnosis of Salpingitis 
Tuberculous Salpingitis 
Syphilis of the Fallopian Tube 
Actinomycosis of the Fallopian Tube 
Parasites of the Fallopian Tube 

New-formations of the Fallopian Tube 



378 
379 

379 
381 
381 
383 
383 
385 
386 
389 
395 
396 
398 
402 
403 
403 
403 



CHAPTER XXXI. 



The Diagnosis of Diseases of the Ovary . . . 407 

Normal Anatomy ........... 407 

Histology 408 

Methods of Examination . . . . . . . . . . 409 

Anomalies of Development . . . . . . . . .410 

Changes in Position . . . . . . . ..... 412 

Descensus Ovarii . . . . . . . . . . . 412 

Hernia ............. 413 

Hypertrophy . . . . . . 414 

Atrophy . 414 

Parasites and Foreign Bodies . . . . . . . .415 

Circulatory Disturbances . . . . . . . . .415 

Inflammations (Oophoritis, Ovaritis) . . . . . . .419 

Acute Ovaritis . 419 

Chronic Ovaritis .......... 420 

Cystic Degeneration ......... 420 

Abscess ............. 425 

Clinical Diagnosis of Ovaritis ........ 426 

Differential Diagnosis . . . . . . . . • 428 

Simple Cysts ■ 429 

Infectious Granulomata . . . . . . . . . .431 

Tuberculosis . . . . . . ... . . 432 

Syphilis 433 

Actinomycosis ........... 433 

Leprosy . . . . . . . . . . • • 433 

New-formations ........... 433 

Etiology 433 

Classification ........... 434 

Carcinoma ,.,...•..•. 441 



CONTENTS xvii 

PAGE 

New-formations — 

Dermoid Cysts 443 

Fibroma 447 

Myoma ............ 448 

Sarcoma . 448 

Endothelioma 449 

Parovarian Cysts .......... 449 

Clinical Diagnosis of New-formations . . . . . .451 

Intraligamentary Development ....... 462 

Adherent Tumors 462 

Torsion of the Pedicle 463 

Rupture of an Ovarian Cyst . . . . . . . . . 465 

Leakage of an Ovarian Cyst ........ 465 

Hemorrhage into the Cyst . . . . . . . . 465 

Suppuration of the Cyst ........ 465 

Malignant Degeneration of the Cyst ....... 466 

Ovarian Tumors Complicating Pregnancy ....... 467 

Diagnosis of the Variety 467 

Fate of Ovarian Tumors . . . . : ... . 468 

CHAPTER XXXII. 

The Diagnosis of Peritonitis .... 470 

General Peritonitis . . 472 

Tuberculous Peritonitis 472 

Carcinomatous Peritonitis ......... 472 

Pelvic Peritonitis . . . 473 

CHAPTER XXXIII. 

The Diagnosis of Parametritis (Pelvic Cellulitis) 479 

Definition 479 

Classification . . . . . . . . ■ . • . . . 479 

Acute Parametritis .......... 480 

Chronic Parametritis .......... 481 

Differential Diagnosis . . . . . . . . . . 483 



PAKT III. 

DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

CHAPTER XXXIV. 

The Diagnosis of Diseases of the Urethra and Bladder . 487 

Anatomy ............ 488 

Physiology . . . 490 



XVIU 



CONTENTS 



Topography 

Natural Landmarks 

Methods of Examining 

Percussion 

Palpation 

Catheter and Sound 

Inspection 

Urethroscopy . 

Cystoscopy 

Segregator 

Malformations and Diseases of the Urethra 

Malformations and Diseases of the Bladder 



PAGE 

490 
490 
492 
492 
492 
493 
493 
494 
494 
509 
510 
515 



CHAPTER XXXV. 

The Diagnosis of Diseases of the Ureters , . 531 

Anatomy . . . ... . . . . . . . . 531 

Physiology . 532 

Methods of Examination .......... 532 

Congenital AnomaUes ..... .... 538 

Ureteritis . . . ' 539 

Obstruction of the Ureter . ....... 541 

Fistula 544 

Injuries ... 545 

CHAPTER XXXVI. 

The Diagnosis of Diseases of the Kidney . 546 

Topography ............ 546 

Methods of Examination .......... 546 

Movable Kidney 548 

Enlargements of the Kidney ......... 550 

Hydronephrosis . . . . . . . . . . . 551 

Pyonephrosis ... ..... ^ . . 552 

Perinephritic Abscess .......... 554 

Tuberculosis ............ 556 

New-formations . . . . 558 

Renal Calculi ............ 564 



CHAPTER XXXVII. 
Diagnosis of the Causes of too Frequent and Painful Urination 



569 



CHAPTER XXXVIII. 
Diagnosis of the Causes of Incontinence and Retention of Urine 



571 



aYNECOLOaiCAL DIAGNOSIS. 



PART I. 
GENERAL DIAGNOSIS. 



CHAPTER I. 

THE CLINICAL HISTOKY. 

In the diagnosis of diseases peculiar to women we have not only 
to recognize the disorders as found in the genitalia, their character 
and extent, but we must take under consideration associated lesions 
and functional disturbances in all parts of the body. To this end 
a systematic general examination should precede the local exami- 
nation, and careful inquiry should be made into the family history 
and into the personal history relative to the social state and 
previous illnesses. 

In order to be successful in the treatment of diseases peculiar to 
women we must duly consider all conditions — physical, social, and 
moral — that influence her well-being. 

A PLEA FOR AN EARLT DIAGNOSIS. 

The importance of an early diagnosis cannot be too strongly 
emphasized. The deplorable mortality in malignant disease, the 
progressive and destructive course of pelvic infections, the remote 
results of traumatisms and displacements of the pelvic viscera 
speak more emphatically than can words for the importance of an 
early diagnosis in diseases of women. The insidious onset of many 
of the lesions, and the existence of malignant growths long before 

2 (17) 



18 GENERAL DIAGNOSIS 

giving rise to a clinical sign, speak for the uncertainty of any pro- 
cedure looking to the early' recognition of pelvic disorders. 

Physicians are too often dilatory in appreciating the necessity for 
examinations and in impressing their patients with the importance 
of an immediate one when there is a suggestion of departure from 
the normal. More frequently, however, the patient is at fault 
through ignorance, indifference, slothfulness, and so-called modesty. 
Thus a delayed menstrual period is unheeded until the rupture of a 
tubal pregnancy; the supposed return of the menstrual flow proves 
to be the bleeding of an inoperable cancer; a leucorrhoeal discharge 
goes unheeded until the infection has spread to the tubes; a pain in 
the back becomes an every-day complaint, yet awakens no suspicion 
of a uterine displacement or a new-growth. And so it is that 
lesions of the pelvic viscera go unrecognized until far advanced and 
oftentimes incurable. A full appreciation of the significance of 
initial disorders will do much to prevent the development of 
disease and to stay its progress. 

THE CLINICAL HISTORY. 

In the making of a diagnosis the first important step is the 
recording of a clinical history. A carefully recorded history has 
many advantages: it serves as a guide to a systematic examination, 
and places before the physician a detailed, logical record of the 
case for future reference. 

It is manifestly impossible to always follow a set form in 
case-taking. Neither is it possible to always adhere to the very 
good general rule of taking the full history at the time of the first 
examination. 

The nervous state of the patient, together with many other 
factors, may preclude the taking of a complete history at the 
time of the first consultation. But at all times certain definite 
items may be recorded, and the history completed at a subsequent 
visit. 

It is good advice given to students in text-books to begin with 
permitting the patient to recite her complaints without interruption. 
The patient becomes self-possessed, while at the same time the 
physician is given an opportunity to observe her general appearance, 
temperament, complexion, nutrition, carriage, and many other 



THE CLINICAL HISTORY 19 

points bearing upon her case. After a time direct questions may 
be put to her, and as the answers are given they may be concisely 
placed on record. 

FORM OF CASE RECORD. 

In all text-books students are given a blank form to be filled out 
in the taking of a history. Such forms are of great service to the 
inexperienced practitioner, but for one who through long experience 
has acquired the art of case-taking they are unnecessary and ill- 
adapted. The allotted space may be inadequate to suit individual 
requirements. The card-index system is gaining favor and is 
highly commendable. For myself, I prefer my letter-head, upon 
which the answers to questions can be hurriedly jotted, and to 
which subsequent notations can be added. This is placed in an 
envelope, on which is recorded the name and address. These 
envelopes can be filed away in alphabetical order. Notes from all 
subsequent examinations, copies of prescriptions, correspondence 
with patient and physician can all be placed in the envelope from 
time to time. When visiting the patient the envelope can be 
placed in the pocket and referred to on the way. 

As a compromise between the elaborate printed forms and the 
blank letter-head, the following form is recommended for sim- 
plicity, accuracy, and liberal spacing: 



Name 


Address 


Date. 


Patient of Dr. 


Address 




Age 


Occupation 


Nationality 


S. M. W. 


Para 


Miscarriages 



Events following childbirths and miscarriages 
General appearance 
Family history 
Previous illnesses 
Present complaints 



20 

Menstrual history 



GENERAL DIAGNOSIS 

Menses began Type 

Quantity Duration 

Pain Menopause 



Intermenstrual pain 



Leucorrhoea 



General physical findings 



Nervous system 



Cardiovascular system 



Digestive system 



Respiratory system 



Urinary system 



Urinalysis: 




• 




Amount in twenty-four hours 


Color 




Sp. gr. 


Reaction 


Albumin 




Sugar 


Total solids 


Urea 




Microscope 


Physical findings in pelvis and abdomen: 








Abdominal wall 








Tender on pressure 


Swellings 




Visceroptosis 









Vaginal outlet 



Vagina 



Cervix 



THE CLINICAL HISTORY 21 

Uterine body- 
Tubes 
Ovaries 
Bladder 



Rectum 

Extragenital structures 
Diagnosis 
Treatment 
Termination 

A brief discussion of the above items will be of interest. 

1. Address. The place of residence is inquired into, not only as 
a matter of business, but also to determine the possible influence of 
the environment upon the general health of the individual. Malarial 
districts, congested portions of the city, extremely warm or cold 
climates exercise a definite influence upon the general and local 
condition of a woman. 

2. Age. The special disturbances found in the various stages of 
life — i. e., infancy, puberty, sexual maturity, climacteric and post- 
climacteric — are at once, suggested when the age of the patient is 
known. 

In infancy malformations and inflammations of the lower genital 
tract are to be looked for; tumors, displacements, and traumatisms 
seldom appear. Infections rarely extend beyond the vagina and 
into the uterus. More often they are limited to the vulva by the 
hymen, which serves as a barrier. 

At puberty malformations of the genital organs are commonly 
first noticed through failure of the menses to appear; congenital 



22 GENERAL DIAGNOSIS 

displacements first cause disturbance at this time, because of the 
increase in the size of the uterus and the estabhshment of the men- 
strual functions; inflammations are usually confined to the vulva, 
rarely extending above the hymen; new-formations and traumatisms 
are seldom observed. 

During the period of sexual maturity all lesions of the genital 
organs may be found. Congenital malformations may first be 
observed after marriage and in childbearing. Inflammatory 
lesions, involving part or all of the genital tract, most often arise 
as the result of childbearing, specific infection, and instrumental 
and digital manipulations. New-formations usually make their 
appearance in this period. Displacements and traumatisms occur 
as the result of childbearing and rarely arise at any other time 
of life. 

In the climacteric and postclimacteric periods all disorders have 
a special clinical significance. The possibility of malignancy should 
always be borne in mind. After seventy years of age it is unusual 
for any lesion to develop. No disorder should be regarded lightly 
when arising at the end of the childbearing period. The onset of 
malignant disease is so insidious and so misleading in its clinical 
manifestations that we cannot afford to look lightly upon any 
disorder, however trivial it may seem to the patient and physician. 

3. Occupation is an important factor in the causation and aggrava- 
tion of pelvic disorders. In young girls confined in workshops the 
menstrual functions are seldom perfectly established. Poor ven- 
tilation, long working hours, heavy lifting, poor food, all exercise 
an unfavorable influence upon the development of the pelvic viscera 
and tend to aggravate existing maladies. On the other hand, 
sedentary and indolent habits are equally injurious. 

4. Nationality. The Jewish race is said to menstruate early 
and to early reach the menopause, but I. know of no proof of this 
statement. The Caucasian race is more subject to carcinoma, 
the African to fibroids. 

5. Social State. It is well to inquire into the social state of the 
patient — to learn whether she is single, married, or a widow. An 
early understanding may forestall an embarrassing question as to 
the sexual relations, and may suggest possible causes for her com- 
plaints. For example, a recently married woman complaining of 
leucorrhoea and painful urination is suspected of being infected. 



THE CLINICAL BISTOBY 23 

The fact that the patient is single or a widow should never mislead 
the examiner in his diagnosis; the possibility of pregnancy and 
venereal infection must always be excluded by the usual methods 
of examination, uninfluenced by the social state of the patient. 
While the physician must be alert to these possibilities he should 
exercise great tact and caution in his inquiries. 

6. Number of Children and Miscarriages. Frequent childbearing 
and miscarriages almost certainly result in some sort of pelvic 
ailment. It is exceptional for a woman to give birth to several 
children without acquiring a pelvic lesion. Complaints dating 
back to a childbirth or miscarriage suggest the probable finding 
of an inflammatory lesion, a displacement, or a laceration. 

The condition of the bowels and bladder, the cardiovascular, 
nervous, and respiratory systems should be carefully inquired into. 

Not infrequently a pelvic lesion is dependent upon a disorder of 
the abdominal or thoracic viscera. Dysmenorrhoea, leucorrhoea, 
uterine hemorrhage, and sterility may be directly referred to a 
general disturbance. An excitable and overwrought nervous 
system alone may be responsible for many of the functional dis- 
orders of the pelvic viscera. Regard for the general condition of 
the patient and a due appreciation of the influence of the general 
upon, local conditions will do much toward eliminating so-called 
*' meddlesome gynecology." 

7. Family History. It is not probable that heredity plays an 
important role in the etiology of pelvic disorders. In tuberculosis, 
and to a lesser degree in carcinoma, the influence of heredity should 
not be underestimated; but in the benign tumor formations, dis- 
placements, and malformations heredity has little or nothing to 
do. It is well to carefully inquire into the family history, but we 
are not to be greatly influenced by it. 

8. Previous Illnesses. Acute infectious diseases, tuberculosis and 
all chronic wasting diseases, anaemias, and long-standing lesions of 
the thoracic and abdominal viscera may both originate and aggra- 
vate disorder in the genital tract. 

General conditions have an important bearing upon the pelvic 
viscera, not only in aggravating the disorders, but in actually 
originating them. It therefore becomes imperative to carefully 
consider all general conditions in relation to their possible bearing 
upon the functional disturbances and lesions of the genitalia. 



24 GENERAL DIAGNOSIS 

9. Present Complaints. The complaints of the patient will often 
serve as a suggestion, but a diagnosis can never be based upon the 
subjective symptoms in the absence of a physical examination. Any 
or all of the pelvic disorders may exist without subjective symptoms. 
On the other hand, there may be serious complaints on the part of 
the patient in the absence of a pelvic lesion. The familiar group 
of symptoms — hemorrhage, pain, leucorrhoea, constipation, and 
backache — are common to many altogether dissimilar lesions in the 
pelvis. We can, therefore, place but little reliance upon the com- 
plaints of the patient, but must depend in great part upon the 
physical findings. Symptoms, at best, are only suggestive of a 
possible lesion. 

10. Menstrual History. So far, we have considered the patient 
from the standpoint of the general practitioner. We now come to 
consider more particularly the disorders of the genital organs. 

HEMORRHAGE FROM THE GENITAL TRACT. 

In diseases of women the most significant of all symptoms is 
hemorrhage. While not in itself diagnostic, it is of the greatest 
value as an indication for an immediate and searching physical 
examination, both general and local. Hemorrhage froiji the 
genitalia comes from the vulva, vagina, cervix, body of the uterus, 
and occasionally from the tubes; never from the ovary except in 
the case of a tubo-ovarian hsematoma discharging its contents into 
the uterus- — a most unusual event. 

From the vulva hemorrhage is the result of trauma, new-forma- 
tions, ulcerations, lupus, cancroid, and rupture of varicose veins 
complicating pregnancy. The origin of the bleeding is recognized 
by direct inspection. 

From the vagina hemorrhage is the result of causes similar to 
those above enumerated. An exceptional cause lies in metastatic 
growths of syncytium (syncytioma malignum). The bleeding site 
is readily disclosed by the vaginal speculum. 

From the vaginal portion of the cervix hemorrhage follows imme- 
diately upon the delivery of the child as the result of lacerations. 
At the end of the childbearing period the most common cause of 
hemorrhage from the cervix is carcinoma. Less frequent causes 
are sarcoma, tuberculosis,- and erosions. 



THE CLINICAL HISTORY 25 

Before considering the morbid conditions causing bleeding from 
the uterus, let us briefly consider what may be looked upon as a 
physiological uterine hemorrhage. 

1. MENSTRUATION. 

No other organism loses so much blood from the uterus as does 
woman. Within certain ill-defined limits this loss of blood is physi- 
ological; hence it behooves us to consider first of all the character 
of the normal menstrual act before taking up the discussion of patho- 
logical bleeding from the uterus. The time of onset of the men- 
strual function varies widely among individuals. Climate has much 
to do with determining the onset, and heredity has some influence. 
In this country Engelmann found the average age to be fourteen, 
in cold climates sixteen, and in warm climates nine years. Later 
observations made by Engelmann led him to the conclusion that 
early puberty is the rule in Arctic regions, rather than at the equator. 
He observed that nutrition and habitation and a lascivious life, with 
early and constant mingling of sexes, might appear to explain the 
early puberty of the Eskimo. 

We are all familiar with instances of precocious menstruation. 
The earliest case occurred in Glasgow at four days of age. Irion 
records a case at seven days, and the literature abounds in cases a 
few weeks and months of age. In nearly all these cases the genitalia 
were abnormally developed; there was hair on the pubis, and the 
breasts were often enlarged. It is not probable that precocious 
menstruation could occur without premature development of the 
menstrual organs, and where this development is not found the 
hemorrhage should not be regarded as catamenial unless it recurs 
at monthly intervals. The mother will bring to the physician a 
napkin marked by a red stain, and will ask if it be possible that 
her child is menstruating. Such stains may be blood from a vulvo- 
vaginitis or urethritis, but are more often deposits of red urates 
or uric acid. 

City-bred girls menstruate six to twelve months earlier than girls 
living in the country (Williams). 

As to the frequency of the menstrual period, it is often stated 
that the normal type is twenty-eight days. But women are rarely 
so regular; there is usually a variation of one or more days. 



26 GENERAL DIAGNOSIS 

Regularity in the menstrual functions adds neither strength nor 
grace. Women menstruate at long or short intervals without ill- 
effect, providing the quantity of blood lost does not materially 
lessen their strength. 

The average quantity of menstrual blood lost in a single period 
is estimated at six to eight ounces — the minimum two, and the 
maximum ten. Obviously what may be regarded as a normal 
quantity for one may be abnormal for another. A plethoric, well- 
nourished woman may menstruate freely for eight days without 
harm, while the same loss of blood in an anaemic individual might 
seriously undermine her strength. 

It is impractical to collect the menstrual blood; therefore the 
amount of blood lost is estimated by counting the number of napkins 
soiled. No exact information is gained by this procedure, because 
the size and quality of the napkins vary, and one woman will 
tolerate an oversaturated napkin, while another will scarcely 
permit the staining. However, we have no better means at our 
command, and by estimating the usual number at fourteen napkins 
in the entire period we arrive at a fair estimate of the amount of 
blood lost during the menstrual period. 

Anatomy of the Menstruating Uterus. Kundrat and Engel- 
mann were the first to record anatomical observations on the men- 
struating uterus. These observations were made on cadavers in 
which the endometrium of the uterine body had undergone fatty 
degeneration and the surface epithelium was exfoliated. 

Later, Williams made postmortem examinations of twelve men- 
struating uteri. Nine of the twelve cases died of acute infectious 
diseases. He found fatty degeneration of the mucosa of the uterine 
body, as did Kundrat and Engelmann, and stated that the entire 
mucosa down to the musculature was exfoliated, that following 
menstruation the mucosa was regenerated from the musculature. 

Leopold recognized the observations of Kundrat, Engelmann, 
and Williams as faulty, in that the changes in the endometrium as 
described by them might result from the acute infections and 
chronic wasting diseases which were the causes of death. He care- 
fully excluded all such cases and selected those of normal menstrual 
type. He failed to observe fatty degeneration of the mucosa, but 
agreed that the surface epithelium was shed in the menstrual 
process. He does not state how long after death the sections were 



PLATE I. 




FIG 3. 



Anatomy of the Menstruating Uterus. 



Fig. 1 represents a specimen renaoved. twenty-six hours after the 
onset of the menstruial flow. It corresponds to the first stage of 
Gebhard. The capillaries, which are rarely visible in the inter- 
menstrual period of the normal uterus, are here shown to be -widely 
dilated ; a serosanguineous exudate permeates the stroma, widen- 
ing the intercellular spaces ; these changes are more marked near 
the surface. The glands are not affected, and the surface epithelium 
is intact and apparently normal. 

Fig. 2 represents a specimen removed on the third day of men- 
struation, and corresponds to the second stage of Gebhard. The 
"subepithelial haematoma " is vi/^ell marked; the surface epithelium 
is lifted from its bed. by the blood beneath ; here and there the blood 
has burst through the epithelial covering and has carried avvay 
with it small bits of epithelium. Fatty degeneration of the mucosa 
is not in evidence. 

Fig. 3 represents a specimen removed the day following the 
cessation of the menstrual flow ; it corresponds to the third stage of 
Gebhard. The bloodvessels are less engorged than in the preceding 
speeinnen ; the blood extravasated into the stroma is less in amount 
and does not give the appearance of fresh blood. The surface epi- 
thelium is intact and closely adherent to the stroma. 



THE CLINICAL HISTORY 27 

made, or the method of preparing the specimens. Within a few 
hours, certainly within twenty-four hours, after death or hyster- 
ectomy the surface epithehum undergoes degenerative changes and 
may be wholly lacking in microscopic sections unless the tissues 
are immediately fixed in formalin or some other fixing fluid. 

It was Moricke who first excluded the possibility of postmortem 
and postoperative changes in the uterus by examining scrapings 
from the normal menstruating uterus. He curetted and made 
microscopic examination of forty-five menstruating uteri in all 
stages of menstruation. In every instance the surface epithelium 
was found intact. In two additional cases I^ohlein reported similar 
findings. 

Westphalen also made a series of examinations of scrapings of 
the mucosa during the various stages of menstruation. In every 
case where the mucosa was normal the entire membrane was well 
preserved; in morbid conditions of the mucosa part or all of the 
surface epithelium was shed. Mandle confirmed these findings. 

The most elaborate observations were carried out by Gebhard in 
Berlin. He not only examined scrapings, but also sections of uteri 
removed during the menstrual period for lesions not involving 
the endometrium. He classifies the anatomical changes into three 
stages : 

1. The stage of premenstrual congestion, in which the capillaries 
of the mucosa are congested; a serous or serosanguineous exudate 
infiltrates the stroma of the mucosa, widening the intercellular 
spaces; later the blood leaves the capillaries and infiltrates the 
stroma, gravitating in the direction of least resistance — i. e., toward 
the uterine cavity, and forming a collection of blood beneath the 
surface epithelium. 

2. The stage of active hemorrhage, in which the blood is forced 
between the epithelial cells into the uterine cavity; here and there 
the epithelium is lifted from its bed, the continuity of the surface 
is broken, and bits of epithelium are accidentally broken off and 
are carried with the menstrual flow. Blood may also find its way 
into the gland lumina. 

3. The stage of postmenstrual involution, in which the bloodvessels 
become less engorged; blood is no longer extravasated into the 
connective tissue spaces; the blood left in the stroma is slowly 
absorbed; the surface epithelium lifted from its bed resumes its 



28 GENERAL DIAGNOSIS 

former place, and lost epitheliuni is rapidly regenerated from 
adjacent epithelial surfaces. 

These three stages are represented in Plate I. The sections here 
illustrated were taken from specimens removed by Dr. J. Clarence 
Webster in the Presbyterian Hospital, Chicago. Nine hysterec- 
tomies were performed by Dr. Webster and one by the author 
during the various stages of menstruation. In the three cases from 
which these specimens were taken the menstrual type was normal. 
In two cases there was an excessive menstrual flow resulting from 
endometritis associated with fibroids. Sections from these two are 
not presented because of the morbid state of the endometrium; in 
them the surface epithelium was not seen. 

Immediately upon removal the uterus was placed in salt solution, 
then taken to the laboratory and placed in Zenker's solution for 
twenty-four hours. Sections were then made from various parts 
of the endometrium^ tubes, and cervix ; they were then carried 
through the usual technique in preparing celloidin sections. 

In five cases the tubes show no changes, and the cervix is some- 
what congested. The anatomical changes characterizing men- 
struation are confined to the mucosa of the uterine body in six 
cases, while in the other three there were similar changes in the 
Fallopian tubes. (See Plate II.) These observations establish the 
fact of tubal menstruation. 

While our knowledge of the physiology of menstruation is far 
from exact, we are in possession of well-established facts relating 
to the anatomy of the menstruating uterus. Moricke, Mandle, 
Gebhard, Herzog, and others have demonstrated beyond dispute, 
as do these specimens here presented, that menstruation is not a 
shedding process, that the loss of epithelium is purely accidental 
and limited. Previous observations were at fault in the technique 
of preparing the sections, and in the selection of material which had 
undergone cadaveric changes and degenerative changes common to 
infectious and chronic wasting diseases. 

The Menstruating Fallopian Tube. 

It has been the consensus of opinion that the Fallopian tubes do 
not take part in the menstrual act. A few cases have been observed 
where blood collected in the tube during menstruation, but it is' 
not proven that in these cases the blood came directly from the 



PLATE II. 




Section of a Fallopian Tube Removed Together with a 

Menstruating Uterus. 

A comparison of the section with those shown in Plate I. suggests a close 
analogy. The mucous membrane is engorged with blood, and free blood is found 
in the mucosa and in the lumen of the tube. The epithelium was found intact. 

Since writing the above the author has examined the tubes removed, together 
with a menstruating uterus, finding, as shown in the accompanying plate, changes 
similar to those in the uterus. 



THE CLINICAL HISTORY 29 

mucous membrane of the tube and not from the uterus. I have 
observed the same histological changes during the menstrual period 
in the tubes and in the uterus. These changes were seen in three 
cases of the nine examined. From these observations I am con- 
vinced that the Fallopian tubes menstruate in a small proportion 
of cases. (See Plate II.) 

In the three instances above referred to the identical changes 
were found in the mucous membrane of the tube (see Plate II.) 
that were found in the endometrium (see Plate I.). The tubes were 
perfectly normal in every respect. J. M. Baldy, of Philadelphia, 
observed a complete inversion of the uterus in which the endo- 
metrium failed to bleed during the menstrual period, but at this 
time blood escaped from the uterine ends of either tube. J. Riddle 
Goffe observed blood issuing from the tubes during menstruation, 
and is of the opinion that the tubes occasionally menstruate. 
That the Fallopian tubes menstruate in a small proportion of 
cases would appear evident from these clinical and histological 
observations. 

2. UTERINE HEMORRHAGE. 

We read in text-books of menorrhagia and of metrorrhagia — the 
former term applied to an abnormal increase in the menstrual flow, 
and the latter to an intermenstrual flow. I would suggest that 
these terms be dropped from common usage because of the impos- 
sibility of distinguishing between the two in many cases. The one 
so often merges into the other in such a manner as to render impos- 
sible a distinction between a menstrual and an intermenstrual flow. 
Then, too, they are dependent upon the same general causes. For 
the sake of simplicity and exactness, we will include both under 
the general head of uterine hemorrhage. 

Systemic Causes of Uterine Hemorrhage. Hemorrhage from 
the uterus may occur as the result of general systemic disturbances 
in the absence of a local lesion. We find that ancemia and plethora 
may cause hemorrhage — anaemia by reason of the low specific 
gravity of the blood and its diminished coagulability, and plethora 
from high vascular pressure. Chlorosis is the exception among the 
anaemias, in that the menstrual fiow is lessened or absent. We 
commonly speak of anaemia as the result of uterine hemorrhage, 
when, as a matter of fact, it is not seldom the underlying cause. 



30 GENERAL DIAGNOSIS 

The author lately operated upon a case diagnosed by Dr. B. W. 
Sippy as splenic ansemia, in which a perfectly normal uterus bled 
excessively every three weeks. Removal of the spleen resulted in 
a rapid restoration of the blood and the disappearance of the 
uterine hemorrhage. Failure to check uterine hemorrhages by 
ergot and curettage is frequently accounted for by failure in recog- 
nizing possible general causes. 

All purpuric conditions may be accompanied by hemorrhage 
from the uterus as well as from other parts of the body. 

The specific infectious diseases may be complicated by hemorrhage 
from the uterus brought about by blood and vascular changes, and 
occasionally by endometritis, in which the cause was a specific 
infection. It is said that emotion will excite a hemorrhage from 
the uterus. I seriously question this statement, for in my own 
experience I have never seen the uterus bleed after a period of 
mental excitement in which there was not found a pathological 
lesion to account for the loss of blood. The mental disturbance 
serves only as an exciting cause of the hemorrhage, but without a 
pathological lesion there would be no hemorrhage. 

Whatever impedes the return flow of blood from the uterus will 
bring about passive congestion in that organ, which in turn may 
result in hemorrhage. In this category may be mentioned dis- 
placements of the uterus, diseases of the heart, lungs, liver, kidney, 
and spleen, abdominal tumors, ascites, and, lastly, chronic con- 
stipation. 

Many an otherwise insignificant local lesion, such as a mucous 
polyp, would probably cause little or no bleeding were it not for 
the passive congestion of the pelvis brought about by the above 
named factors. 

Local Causes of Uterine Hemorrhage. Subinvolution of the 
uterus, the result of postabortive and puerperal infection, may be 
regarded as the most prolific source of pelvic disorders in the female. 
It is the starting point of many displacements and inflammations 
which eventuate in uterine hemorrhage. The uterus is enlarged 
in all its diameters, and is deeply congested. Such an organ rarely 
maintains its position because of an increase in weight and a lack 
of support from the ligaments and pelvic floor, which have been 
stretched and torn in labor. The usual factors in the development 
of subinvolution are early rising from childbed, traumatisms in 



THE CLINICAL HISTOB Y 31 

Idbor and infection following labor, and abortion. In this con- 
nection it is to be remembered that retained placental tissue will 
result in subinvolution of the uterus, and may remain organically 
attached to the uterus for days, months, and even years, keeping 
up irregular hemorrhages. 

Endometritis is commonly recognized by the symptoms — hemor^ 
rhage, pain, and leucorrhoea. One or all of these symptoms may 
be absent, and the diagnosis must finally rest upon the micro- 
scopic examination of scrapings from the endometrium. Indeed, a 
positive diagnosis of endometritis can he made only by the microscope. 
, When hemorrhage exists it is usually in the form of an increase in 
the menstrual flow — rarely as an intermenstrual flow. Olshausen 
has described a lesion which he calls fungus endometritis, and bases 
his clinical diagnosis upon the presence of hemorrhage in the 
absence of pain and with little or no leucorrhoea. The endometrium 
is greatly thickened and thrown into folds and fungus-like masses, 
which, under the microscope, are seen to consist of a meshwork of 
enlarged and greatly distended glands, with but little interglandular 
connective tissue. Another variety of endometritis, usually result- 
ing in a profuse menstrual flow, is the polypoid. Mucous polyps 
of the uterus are generally of inflammatory origin. Some authors 
believe them to be invariably of inflammatory origin, while all 
admit that they are in large part so. Hemorrhage is not an invari- 
able symptom of polyps of the uterus, and their presence may 
be accidentally discovered by the curette or after the removal of 
the uterus for other reasons. 

In general, it may be said that uterine 'fibroids of whatever variety 
can only cause hemorrhage from the uterine cavity when the tumor 
involves the endometrium. Fibroids rarely bleed; the hemorrhage 
comes from the endometrium. Furthermore, the hemorrhage is not 
proportionate to the size of the tumor. Submucous fibroids always 
cause bleeding unless so large as to distend the uterus, which would 
result in pressure atrophy of the mucosa and possible adhesions 
between the uterus and tumor. In this event there could be no 
bleeding from the endometrium. Intramural fibroids, if in any 
way influencing the endometrium, may cause bleeding, but sub- 
peritoneal fibroids cannot. We are therefore able to determine 
something of the position of the growth by the presence or absence 
of hemorrhage. 



32 GENERAL DIAGNOSIS 

I have observed a number of cases of postclimacteric hemorrhage 
caused by fibrous polyps of the cervix. It appears that such polyps 
are prone to develop at this time of life. 

One of the earliest symptoms of cancer and sarcoma of the uterus 
is hemorrhage. Yet these growths may be far advanced before 
hemorrhage or any other symptom is manifest. It is for this reason 
that malignant diseases of the uterus are so rarely observed in time 
to effect a radical cure. When hemorrhage does make its appear- 
ance it is too often looked upon as an irregularity of the menopause. 
Our statistics in carcinoma of the uterus would he greatly bettered 
if all hemorrhages occurring at the time of the menopause and after 
this period were viewed with suspicion, and the cause sought for, 
rather than that all irregularities he ascrihed to the menopause. 

There is a malignant growth which I will only refer to. It is 
usually called syncytioma malignum, and is a malignant degener- 
ation of placental tissue. Hemorrhage is the earliest symptota, and 
it may be laid down as a rule that when an irregular hemorrhage 
follows late upon childbirth, hydatid mole, or abortion, the possi- 
bility of malignant degeneration of placental tissue must be borne 
in mind. The diagnosis can only be determined by an exploratory 
curettage and microscopic examination of the scrapings, together 
with the clinical course. (See page 363.) 

When hemorrhage occurs during or immediately after the third 
stage of labor, it is possible that placental tissue is retained in the 
uterus, or that the uterus is relaxed from fatigue and overstretching. 

Improbable as it may seem, death from hemorrhage rarely 
follows rupture of the uterus; it is more likely to occur from sub- 
sequent infection. 

The persistence of menstruation during pregnancy should be 
regarded as a morbid condition and not as a perverted physiological 
type, as it is generally thought to be. I believe that in every instance 
there is a pathological lesion to account for the loss of blood. 

Montgomery observed a case in which there was a profuse 
hemorrhage at the time of the first menstrual period following 
conception. She learned to regard the hemorrhage as evidence of 
her pregnancy. Baudelocque and Deventer reported cases in which 
the menses only appeared during pregnancy and ceased at the ter- 
mination of pregnancy. The hemorrhage may appear at any month 
of pregnancy, but with greater fre(|uency in the early months. In 



THE CLINICAL HISTORY 33 

all such cases great caution should be exercised in the diagnosis of 
the cause of the hemorrhage. Before it can be regarded as men- 
strual blood a most searching examination must be made for the 
purpose of excluding such possible causes as placenta prsevia, double 
uterus, fibroids, carcinoma, mucous polyps, and ectopic pregnancy. 

I will only refer to 'placenta prcevia, hydatid mole, premature 
detachment of the placenta, and ectopic pregnancy as causes of 
uterine hemorrhage. 

Arteriosclerosis alone has been charged with the responsibility of 
uncontrollable uterine hemorrhage by Herman, Martin, Reinecke, 
and Kiistner. The charge cannot be wholly sustained, because in 
none of their cases is there a record of having excluded other possible 
causes lying beyond the uterus. Reinecke and Martin performed 
hysterectomy in thirteen cases for the control of hemorrhage, and 
in all the removed uteri the arteries were found sclerosed; but 
they did not exclude the possibility of obstruction to the return 
circulation from such causes as diseases of the heart and lungs, 
thrombosis of the venous trunks, and portal congestion from what- 
ever cause. My point is that in the light of twelve cases reported 
by von Kahlden, Popoff, Herxheimer, and Dietrich, and the one 
I reported, arteriosclerosis per se is alone insufficient to cause a 
hemorrhagic infarction of the uterine tissues or hemorrhage into 
the uterine cavity. In the eight cases reported by von Kahlden 
the postmortem findings showed anatomical hindrances to the 
general circulation in every case. There was pneumonia in two of 
the cases, pulmonary emphysema and bronchitis in three cases, 
cancerous infiltration of the lungs and liver in one case, pulmonary 
infarcts in another, and in four of the eight cases there were cardiac 
lesions. In the case of Popoff there were granular nephritis and 
heart thrombi, pleural effusion, and infarction of the lung and brain. 
In Herxheimer's case there w^as an hypertrophied heart and thrombi 
in the left ventricle and right auricle, granular nephritis, and 
atheroma of the aorta. In my own case hemorrhage did not occur 
until there was an additional obstruction to the circulation caused 
by the plugging of the uterine artery. It is, therefore, not conclu- 
sively demonstrated that arteriosclerosis can in itself be the cause 
of uterine hemorrhage. It would appear that there must be addi- 
tional causes for obstruction, such as were found in the above 
recorded cases. (See Plate III.) 

3 



34 GENERAL DIAGNOSIS 

In the so-called "apoplexia uteri/' it is probable that the hemor- 
rhages are not caused by the rupture of the bloodvessels, but rather 
are due to capillary oozing. This would account for the hemor- 
rhagic infiltration being so removed from the sclerosed vessels in 
the cases of von Kahlden. 

Respecting the etiology of arteriosclerosis of the uterine vessels 
and hemorrhagic infarction of the uterus, little can be said. Age 
varies within the limits of fifty and eighty-seven years. Pregnancy, 
menstruation, and inflammation of the uterus have some bearing 
upon the etiology. The causes of arteriosclerosis elsewhere in the 
body would obtain in the uterus — i. e., alcoholism, chronic malaria, 
chronic lead poisoning, syphilis, etc. 

Referring to the frequency of the lesion, it is not unlikely that 
arteriosclerosis of the uterine arteries and hemorrhagic infarction 
of the uterus are often overlooked in clinical and postmortem 
examinations. It is probable that many cases of so-called "senile 
endometritis" and *' hemorrhagic metritis of the menopause" are 
in reality hemorrhagic infarction of the uterus, and have as an 
underlying factor arteriosclerosis and calcareous degeneration of 
the uterine vessels. The fact that these cases occur in advanced 
years, that they may not be associated with leucorrhoea, and that no 
cause may be found for the hemorrhages, either by clinical exami- 
nation of the uterus and adnexa or microscopic examination of 
scrapings from the endometrium, would be strong evidence in favor 
of the view that these cases are not infrequently hemorrhagic 
infarcts of the uterus and that the primary lesion lies in the blood- 
vessels. 

As to the diagnosis, we are usually content to call such cases 
endometritis when there is no demonstrable cause for the hemor- 
rhage. If an exploratory curettage is made with negative find- 
ings, the indefinite diagnosis of metritis will probably be given, 
particularly when the uterus is of dense consistency and uni- 
formly increased in size. It is possible that the increase in the 
connective tissue of the myometrium may interfere with the circu- 
lation, but it is altogether certain that in many cases the primary 
cause lies in the walls of the bloodvessels, and the hyperplasia of 
the uterus is secondary. It is altogether probable that arterio- 
sclerosis of the uterine vessels may exist without symptoms, and, 
as above stated, there probably must be some additional obstruc- 



PLATE III. 








^ ' 






V 






- "/- >\/ /.>' ^ 



y ' T 



:*> ; 













; -^z 











f/ 



i^- 




CA. 






/ 



r'i-f - -j^ - li?^: 



SSffi^^^Sf^' 









Arteriosclerosis and Calcification of the Uterine Arteries. 

M. Musculature. 

E. Endometrium with effused blood. 
C. Calcareous deposits in vessel wall. 
CA. Congested vessels. 



THE CLINICAL HISTORY 35 

tion to the return circulation in order to cause hemorrhage, which 
event alone is suggestive of the lesion. The clinical diagnosis is, 
therefore, at best uncertain. If hemorrhage occurs in the climac- 
terium or near the time of the menopause, and there can be found 
no local cause for the hemorrhage, either in the presence of new- 
growths of the uterus and adnexa, in the position of the uterus, or 
in the microscopic examination of the uterine scrapings, then it is 
fair to presume that arteriosclerosis of the uterine arteries exists. 
If, in addition to this, there is found arteriosclerosis of the periph- 
eral arteries of the body, and there exists a disease of the viscera 
to account for an obstruction in the return circulation from the 
pelvis, then it is fair to further presume that a hemorrhagic infarc- 
tion of the uterus is present, and that the uterine hemorrhages are 
due to a hemorrhage into the tissues and cavity of the uterus. It 
is not probable that the sclerosed vessels will be found in the scrap- 
ings, because they commonly lie in the outer half of the uterine 
musculature. Caution must be exercised in the liability of mistaking 
the compressed glands for cancer nests. 

Finally, it may be said that the popular impression that the flow is 
increased in the climacteric leads to disastrous consequences. No 
increase in the menstrual flow at the time of the climacteric should he 
regarded as normal or of no clinical importance. A searching exami- 
nation is imperative. 

The character of the discharged hlood varies not only in amount, 
but in color and consistency; and from these characteristics some- 
thing may be inferred as to the origin of the hemorrhage. The 
menstrual blood is usually thin and of a bright-red to a dark-brown 
color. Coagulation is hindered by the alkaline reaction of the 
uterine secretions. Coagulated menstrual blood is always abnormal. 

Coagulation of the blood may occur in endometritis, uterine 
fibroids, carcinoma, polyps, and abortion. When of a dark, 
brownish-red color it is inferred that the passage of the blood has 
been obstructed, giving time for coagulation within the uterine 
cavity. When mucus is intimately mixed with the blood it indi- 
cates an involvement of the cervix from cervical catarrh, polyp, 
carcinoma, or sarcoma. 

Blood of a syrupy consistency is supposed to have remained a 
long time in the uterine cavity. Tissue fibres mixed with the 
blood suggest the presence of degenerated new-growths. 



36 GENERAL DIAGNOSIS 

AMENORRH(EA. 

Physiological Absence of Menstkuation. 
General Causes. 
Local Causes. 
Menstrual Molimina. 

In determining the causes of amenorrhoea it is well to bear in 
mind the physiological conditions in which the menses fail to 
appear. 

A Physiological Absence of Menstruation Occurs: 

1. Before puberty. 

2. During irregular intervals at the time of the establishment of 
menstruation. 

3. During pregnancy and lactation. 

4. During the establishment of the climacteric — "dodging period." 

5. After the menopause. 

When the menstrual flow is retarded or when the quantity is less 
than normal we speak of the condition as amenorrhoea. The term 
may be further qualified by the words relative and absolute. 

By relative amenorrhoea is meant a menstrual flow that is below 
the normal amount for the given individual. That which is abnormal 
for one may be normal for another, depending upon the general 
condition of the individual. 

By absolute amenorrhoea is meant a total suppression of the 
menses. 

The causes of amenorrhoea are both general and local. 

General Causes of Amenorrhoea. 1. Debilitating diseases, such 
as primary ansemia, diabetes, Bright's disease, tuberculosis, malaria, 
and nervous diseases. Chlorosis is probably the most common cause 
of amenorrhoea in girls. In determining the cause of amenorrhoea it 
is not enough to establish the fact of ansemia, but we must ascertain 
the character of the ansemia by an analysis of the blood, and, if 
possible, demonstrate the underlying cause. 

Among the general causes of secondary anaemias we find two 
groups — those caused by deficient nutrition and those caused by 
increased waste. Digestive and respiratory disorders limit the supply 
of blood and oxygen essential to the proper nourishment of the 
body, and, indirectly, to the performance of the menstrual functions. 



THE CLINICAL HISTORY 37 

Hemorrhage from any part of the body, chronic diarrhoea, con- 
tinued suppuration, albuminuria, and the hke, result in excessive 
waste that will bring about amenorrhoea. 

2. Changes in environment are often followed by amenorrhoea for 
a variable length of time. Girls coming from foreign countries to 
the United States commonly experience a delay in the appearance 
of the menses for a variable time. 

3. Mental shock and anxiety may cause a suppression of the 
menses. The fear of conception may suppress the menstrual 
periods, and when the fears are allayed the menses may promptly 
return. 

4. "Catching cold" is a term in ordinary usage, implying a con- 
gestion of the pelvic viscera. Part or all of the menses may be 
suppressed by exposure to cold during and immediately before the 
menstrual period. 

5. Acute infectious diseases, including diphtheria, pneumonia, and 
scarlet fever, and acute articular rheumatism may be followed by a 
period of amenorrhoea, and may result in permanent suppression 
of the menses through degenerative changes in the uterus and 
ovaries. 

6. Nervous diseases, including cretinism, melancholia, various 
forms of insanity, and imbecility, are not infrequently responsible 
for amenorrhoea. In many instances the amenorrhoea is thought 
to be the exciting cause of the nervous disorders. 

7. Morphinism is a possible cause of amenorrhoea. The same is 
said of alcoholism. 

8. Temporary amenorrhoea is not uncommon in young women as 
a result of worry and anxiety, change of residence and mode of 
life. In every instance the possibility of pregnancy must be borne 
in mind, and when it cannot be positively excluded the patient must 
be kept under observation until such time as positive signs of 
pregnancy would be manifest. 

Local Causes of Amenorrhoea. 1. Congenital absence of the 
organs essential to menstruation, namely, the uterus and ovaries. 

2. Hypoplasia and atrophy of the organs essential to menstruation, 
a condition often due to chlorosis. 

3. Retention of the menses from atresia of the cervix and vagina, 
imperforate hymen, and tumor formations obstructing the outflow 
of the menstrual blood. (See Chapter XXIII.) 



38 GENERAL DIAGNOSIS 

4. Removal of the uterus and ovaries, doing away with the men- 
strual flow. 

5. Diseases of the genital organs, disabling and destroying the 
tissues essential to menstruation — that is to say, metritis, endo- 
metritis, chronic ovaritis, cystic degeneration of the ovaries, and 
new-formations in the uterus and ovaries are seldom causes of 
amenorrhoea. 

6. Adiposity associated with anaemia. 

7. Amenorrhoea may exist without apparent cause. 

Effects of Ovariotomy on Menstruation. In this relation it is 
interesting to note the effect upon menstruation of the removal of 
the ovaries. After both ovaries are removed menstruation stops 
abruptly in 66 per cent, of cases. In the remaining 33 per cent, 
menstruation stops gradually throughout a period of one to six 
months. 

The diagnosis of amenorrhoea is made solely upon establishing 
the fact of the non-appearance of the menstrual flow. Such a 
diagnosis is of little value unless the cause of the amenorrhoea is 
clearly established. Pregnancy must always be excluded before 
considering other possible causes, and in doing so it is often neces- 
sary to observe the patient for a limited period. 

The cause of uninterrupted menstruation after double ovariotomy is 
explained by the presence of a supernumerary ovary or by the 
accidental leaving of a bit of ovarian tissue adherent to the neigh- 
boring structures. A small portion of the ovary may have been 
constricted off from the parent ovary by contracting bands of 
adhesions, and may escape notice in the removal of the ovary. 
The law of persistence of habit may explain an occasional case. 
More often a flow persists as the result of a uterine tumor or an 
inflammatory lesion, and is not, strictly speaking, a menstrual 
flow. 

Menstrual Molimina. The local and general disturbances which 
occur at the time when the menses should appear, but fail because 
of the above-named causes of amenorrhoea, are included in the term 
menstrual molimina. These disturbances are pain in the region of 
the ovaries, in the back, and radiating to the thighs ; also flushing 
of the face, dizziness, palpitation, and headache. The duration of 
these symptoms varies from a few hours to the entire month. The 
menstrual molimina generally begin about one month after the 



THE CLINICAL HISTORY 39 

removal of the ovaries, and extend over a period of one or two 
jeai's, sometimes much longer. 

Vicarious Menstruation. Vicarious menstruation is a discharge 
of blood at the menstrual period from some part of the body other 
than the uterus. It may occur simultaneous with the uterine men- 
strual flow, or in the absence of all bleeding from the uterus. 
Almost all mucous and cutaneous surfaces have been known to 
menstruate vicariously, notably the nose, stomach, intestines, and 
bronchi. The urethra, bladder, throat, and ear bleed less fre- 
quently. Instead of blood other discharges may take place. Cases 
have been recorded of periodical diarrhoea, leucorrhoea, and secre- 
tions of milk from the breast. Ulcers and cicatrices have been 
known to bleed at the menstrual period. A nsevus on the face has 
been known to bleed simultaneously with the menstrual flow. The 
cervix was observed to menstruate by Ashton after the removal of 
the body of the uterus and ovaries. 



PAIN IN THE PELVIS DURING MENSTRUATION— 
DYSMENORRHCEA. 

Primary. 

Secondary. 

Membranous Dysmenorrhcea. 

Nasal Dysmenorrhcea. 

Pain in the pelvis is often referred to the uterus or ovaries. Of 
all pains in the abdomen the so-called ''ovarian pain" is by far the 
most usual. Experience teaches us that pain is referred to the 
ovary of the left side three times as frequently as to the right. 
There is no satisfactory explanation for this. It is a matter of 
every-day clinical experience that the pain is often referred to the 
left ovary when there is no apparent disease in either ovary; more 
than that, there may be no demonstrable lesion in the pelvis. Yet 
more strange is the finding of the lesion in the right ovary and the 
pain referred to the left ovary. The author makes no attempt to 
explain these facts. Certain it is that reflex pains may be located 
in the ovary and the lesion confined to the uterus or opposite ovary. 
We are not to infer from complaints of pain in the ovary that 
this structure is diseased, but such pains may well suggest possible 
lesions in one or more of the pelvic viscera. Such pains are 



40 GENERAL DIAGNOSIS 

particularly frequent and severe at the time of the menstrual period. 
This brings us to the discussion of dysmenorrhoea, a term often 
misused and little understood. 

Ernest Herman estimates that only 40 per cent, of women men- 
struate without pain, and that 10 to 20 per cent, of unmarried 
women are bedridden with pain during a part or all of the men- 
strual period. 

Primary Dysmenorrhoea. In determining the cause of dysmenor- 
rhoea we must first consider the condition of the nervous system. 
A condition causing pain in one individual may be unnoticed in 
another of more stable equilibrium. When pain in the pelvis is 
complained of during and between the menstrual periods and a 
thorough examination reveals nothing abnormal in the pelvis, we 
are in the habit of concluding that the fault lies in a functional 
derangement of the nervous system, and we vaguely apply the 
terms hysteria, neurasthenia, and neuroses. A certain degree of 
pain during the menstrual period may be considered within normal 
limits, and in very nervous women such pains may become exagger- 
ated to actual suffering. 

My personal opinion is that severe dysmenorrhoea in the absence 
of pelvic abnormalities is rare. The individual becomes more and 
more nervous as the result of her periodic suffering. Nothing is 
more frequent than such a statement. I am, therefore, inclined to 
regard the general nervousness as an effect rather than a cause of 
the menstrual pain. The local disorder may be nothing more than 
a tetanic contraction of the sphincter uteri, which is wholly wanting 
in the intermenstrual period. Such cases respond to dilatation of 
the cervix. Such are the cases which are relieved by childbearing. 

The explanation of the ^'normal" menstrual pains is probably 
found in the engorgement of the endometrium, which, acting as a 
foreign body, excites the uterus to contract; and it is these uterine 
contractions which occasion the pain. In many of the patho- 
logical lesions involving the pelvic viscera the menstrual con- 
gestion is added to the already engorged tissues, and the pain is 
severe. It is exceptional for pathological lesions to exist in the 
uterus and adnexa without dysmenorrhoea, but knowing such to be 
possible, and, on the other hand, knowing that pain of equal inten- 
sity may exist in the absence of a pathological lesion, we are at a 
loss to know how much the pain is due to structural changes and 



THE CLINICAL BISTORT 41 

how much to an excitable nervous system. We may speak of 
idiopathic or primary dysmenorrhoea when it is evident that the pain 
bears no relation to pathological lesions of the genitalia, and of 
secondary dysmenorrhoea when it is evident that the pain is the 
direct result of a morbid condition in the genital tract. 

Secondary dysmenorrhoea may be caused by all lesions of the 
genital tract. These may be classified under: 

1. Maldevelopments and malformations, which cause menstrual 
pain by obstructing the outflow of the menstrual blood. In this 
category may be included absence or atresia of the vulva, vagina, 
and cervix. The menstrual molimina are experienced, but with- 
out a show of blood. With the return of each monthly period the 
pain increases in intensity as the result of accumulated blood within 
the vagina, uterus, tubes, and, possibly, the pelvis. The obstruc- 
tion may not be complete, and the retarded blood, having time to 
coagulate, is then expelled with cramping-like pains — the so-called 
' ' obstructive dysmenorrhoea . ' ' 

Superinvolution of the uterus is associated with painful men- 
struations, the cause of which is not understood. A congenitally 
small uterus (infantile) is likewise associated with dysmenorrhoea. 
In either case the explanation possibly lies in the encroachment of 
the tissue fibres upon the nerve filaments of the uterus. 

2. Malpositions of the uterus and adnexa are less frequently the 
cause of dysmenorrhoea than are the associated lesions. It is 
exceptional for the menstrual blood to be obstructed in its outflow 
by the bending or twisting of the long axis of the uterus. Pain is 
more often the result of complicating lesions in and about the uterus 
and its appendages. 

Anteflexion of the uterus, when extreme, is almost always asso- 
ciated with pain. The cause of the pain in these cases is still a 
matter of controversy. It is not probable that the canal is ob- 
structed by the bending of the uterus. Hypersesthesia resulting 
in muscular spasms of the internal os is a more satisfactory 
explanation for the obstruction. It is evident that the pain in 
such cases is largely neurotic in origin. 

Anteflexion of the uterus is said to be a frequent cause of dys- 
menorrhoea in virgins and nulliparous married women. In these 
cases it is often observed that a small sound will pass the internal 
OS, yet there is evidently mechanical obstruction to the outflow of 



42 . GENERAL DIAGNOSIS 

the menstrual blood. The explanation lies in the swelling of the 
mucous membrane during the menstrual period. The passing 
sound compresses the swollen mucosa. 

3. In inflammatory diseases of the uterus and adnexse, which are 
more or less tender and painful in the intermenstrual period, the 
suffering is greatly intensified by the menstrual flux — ''congestive 
dysmenorrhoea." Plugs of tenacious mucus may fill the cervical 
canal and obstruct the menstrual flow. 

4. New-formations in the genital tract may obstruct the menstrual 
blood — "obstructive dysmenorrhoea." Pelvic tumors share in the 
menstrual congestion, and by their enlargement the pressure symp- 
toms are intensified. 

Schultze has lately (Monatsch. f. Geb. u. Gyn., December, 1903) 
suggested an explanation for dysmenorrhoea occurring in young 
girls and young women in whom nothing abnormal was discovered 
to account for the pain. He suggests the possibility of hypoplasia 
of the uterine musculature being present, and hence the uterus is 
unable to expel the menstrual blood as fast as it accumulates in 
the uterus. In this condition two sorts of pain may arise, pre- 
menstrual and menstrual, the former being due to tension in the 
congested uterus. In these cases pregnancy often results in a cure 
because of the development of the uterine musculature. 

Membranous dysmenorrhoea is a term first applied by Morgagni. 
In this condition there is a discharge at the menstrual period of a 
part or the whole of a cast of the uterine cavity. The discharge of 
the membrane may occur but once or at each menstrual period. 
If we believed that the endometrium is shed at each menstrual 
period we might conclude that membranous dysmenorrhoea is 
merely an exaggeration of the normal process. The membrane 
may be shed as a complete triangular cast of the uterus, or may 
be discharged in shreds. 

Membranes are more frequently passed in the menstrual flow 
than is known. Without a systematic examination of the clots 
expelled such membranes will often escape notice. Sir I. Williams 
found membranes in three-fourths of his cases of dysmenorrhoea 
and Scanzoni in two-thirds. They may be passed without pain. 
The possibility of monthly abortions must be borne in mind. 
Virgins and sterile women are most affected, though the disease is 
not unknown to women who have borne children. The diagnosis 



THE CLINICAL HISTOHY 43 

must rely upon a careful examination of the expelled membrane. 
(See Chapter XVI.) 

Under the microscope we see a great variation in structure. The 
membrane may resemble an hypertrophied endometrium, a decidua, 
or a fibrinous membrane. 

Accompanying the discharge of the membrane is intense pain. 
The membrane is not to be mistaken for the decidua of extra- 
uterine or intrauterine pregnancy. 

Nasal Dysmenorrhoea. Fliess, in 1897, demonstrated a definite 
relationship between the mucous membrane of the nose and the 
genitalia in women. He observed certain swollen and tender red 
spots ("genital spots") on the nasal septum and inferior turbinate. 
Schiff made a number of clinical observations and conclusively 
demonstrated that temporary relief is often afforded by cocainizing 
these genital spots, and that permanent relief can be afforded by 
the use of the cautery. Ephraim treated twenty-four cases with 
eight good results. These reflexes together with the established 
fact of vicarious menstruation from the nose would appear to 
establish beyond a doubt an intimate relationship between the 
nasal and genital passages. In the cases above referred to great 
caution was exercised in excluding the influence of mental sug- 
gestion. The author is inclined to agree with Kolischer that the 
procedure is irrational and will not stand the test of time. 

THE DIAGNOSIS OF THE CAUSES OF STERILITY IN WOMEN. 

Before entering into a discussion of the various causes of sterility 
in women let us clearly understand the clinical significance of the 
term sterility and the conditions essential to conception. 

By sterility we mean an incapacity for childbearing. This 
definition may be further qualified by the terms "absolute sterility" 
and "relative sterility." Sterility is absolute when the individual 
is incapable of bearing a child to the period of viability; she may 
conceive, but habitually aborts before the period of viability. 
Sterility is relative when childbearing is not in accordance with 
conditions, age, and length of married life. We may speak of 
relative sterility when three years have elapsed since the last child- 
birth, or when conception has not taken place within three years 
from date of marriage — this time limit is, of course, purely arbitrary. 



44 GENERAL DIAGNOSIS 

M. Duncan found that in one-sixth of all cases parturition occurred 
before the lapse of the first year after marriage, and in the second 
year four-sixths of all marriages were fruitful. 

Again, we may speak of sterility as primary and secondary: 
primary when the conditions which preclude the possibility of child- 
bearing are primary, and secondary when after the birth of one or 
more children there is acquired an incapacity for childbearing. 

Periods of fifteen and even twenty years have intervened between 
successive childbirths, and this in the absence of any apparent 
cause for sterility. 

The conditions essential to conception are briefly enumerated as 
follows : 

1. Deposit of semen containing living, active spermatozoa in the 
upper segment of the vagina. 

2. Passage of the spermatozoa through the cervix into the cavity 
of the uterus. It is said that spermatozoa will not live longer than 
twelve hours in the acid secretions of the vagina; while in the 
uterus and tubes they commonly retain their vitality six to eight 
days. Leopold reported a case of a woman in his clinic who had 
not had sexual intercourse for thirty-seven days prior to the opera- 
tion, when, on abdominal section, living, active spermatozoa were 
found in large numbers in the fimbriated end of the tube. This 
case, with many other observations on women and lower animals, 
has led to the statement that fertilization of the ovum commonly 
takes place in the tube. 

3. A healthy ovum must find an uninterrupted passage from the 
ovary, through the tube, and on into the uterine cavity. 

4. The fertilized ovum must find a permanent resting-place on 
the endometrium until the period of viability. 

With the above definitions of sterility and the conditions essential 
to conception set clearly before us we are now in a position to 
consider the factors which tend to prevent conception. 

In seeking the cause of sterility, not only the whole range of dis- 
eases peculiar to women must be considered, but as well the general 
physical and social conditions of the individual. More than this, 
we are not to conclude that the cause of sterility is necessarily 
found in the woman; full one in six sterile marriages are chargeable 
to the husband. One marriage in ten is non-productive, and, with 
few exceptions, sooner or later the advice of the physician is sought. 



THE CLINICAL HISTORY 45 

The subject is therefore of prime iniportance to the physician, and 
no condition more thoroughly taxes the skill of the general practi- 
tioner and specialist. 

General Causes. In determining the cause of sterility we should 
first consider the general conditions predisposing to sterility, and 
first of these is age. No cause of sterility approaches age in extent 
and power. The most prolific time of life is between the ages of 
twenty and twenty-four. Pregnancy may occur before the menstrual 
period, as so often happens in India, where it is considered a sin 
to let pass an opportunity for conception — a sin equivalent to 
infanticide. Because of this belief it is customary, in such countries, 
to marry before puberty. Marriages occurring between fifteen and 
twenty years of age are relatively sterile as compared with those 
occurring between twenty and twenty-five. The explanation lies 
in the more mature development of the sexual organs after twenty 
years of age. A case is recorded where a woman gave birth to 
twelve children before her menstrual flow appeared. Again, it is 
possible for pregnancy to occur long after the cessation of the 
menstrual period. Trento reported a case of a woman who gave 
birth to a child at sixty-seven years of age. Abraham was one 
hundred years of age and Sarah ninety when their child was born. 
Sarah ^'was old and well stricken with years, and with whom it 
had ceased to be as it is with women" — that is, she had ceased to 
menstruate. Renauden reported the case of a woman who was 
delivered of a child ten or twelve years after the cessation of the 
menstrual periods. So, while pregnancy is possible after the meno- 
pause, the rule is that the capacity for childbearing ceases four to 
six years before the cessation of the catamenia. 

(a) Ansemia, either primary or secondary to some wasting disease, 
such as tuberculosis, diabetes, nephritis, and malaria, is an im- 
portant predisposing factor, and must always be taken into account 
whatever else may be found. 

{h) Marriage of near relatives is said to be a cause of relative 
sterility, but this statement is not confirmed. G. Darwin has 
proved the harmlessness of marriages between cousins, and has 
demonstrated the fertility of such marriages. 

(c) Obesity is undoubtedly a potent cause of sterility. That 
peculiar form of obesity associated with anaemia especially con- 
duces to sterility. Scanty nutrition has little or no influence. When 



46 GENERAL DIAGNOSIS 

a woman rapidly increases in weight she very often becomes sterile, 
and in such the most promising means of relieving sterility is to 
reduce the weight. 

{d) Alcoholism is an indisputable factor; furthermore, the death 
rate among children born of inebriate mothers is double that of 
temperate parentage. 

(e) The sexual instinct evidently has some influence upon the 
fertility of women. While it is true that many women bear children 
who have never experienced sexual desire, it is the rule that women 
are most likely to conceive who have the greatest sexual vigor. 

(/) Sexual excess, on the other hand, conduces to sterility through 
the congestion and inflammation resulting from such excesses. 

{g) Sexual incompatibility is an ill-defined condition that plays a 
role in the causation of sterility, though no explanation is offered. 
We are reminded of the marriage of Josephine and Napoleon. 
Many unhappy yet fruitful marriages disprove this theory. As a 
rule some other explanation for the sterility is found. 

(k) Influence of Temperature and Climate. The action of heat 
and cold in the various zones does not appear to affect fertility. 

Local Causes. Having considered the above general predisposing 
causes, we now look to the more tangible local factors. 

(a) Dyspareunia is not an uncommon cause of sterility, and in every 
case the underlying cause of painful coition must be determined. 
We look for lesions obstructing the lower genital passage, such as 
acquired and congenital atresia of the vulva and vagina; over- 
growth of the labia and clitoris, and tumors of the vulva, vagina, 
and uterus, which encroach upon the lower passages. We also look 
for lesions causing pain, such as urethral caruncle, inflammatory 
lesions of any portion of the genital tract; inflammation of the 
urethra and bladder, and for- painful lesions of the rectum, including 
fissure and hemorrhoids. Vaginismus without a recognizable lesion 
is an occasional cause of dyspareunia. It is not essential to concep- 
tion that sexual union be complete. This is demonstrated by the 
fact that pregnancy may occur with an intact hymen and in the 
presence of other evident obstructions to complete sexual union. 

(h) The maldevelopments and malformations of the genital organs 
are occasional causes of absolute sterility. The absence of any of 
the reproductive organs, or the failure of these organs to fully 
develop, are certain causes of sterility. A uterus partially or com- 



THE CLINICAL HISTORY 47 

pletely divided is not likely to become pregnant, and a septum 
dividing the vagina may offer an obstruction to sexual intercourse. 
When a woman complains of amenorrhoea, or at most of a scanty, 
irregular flow which has persisted from a delayed puberty, it is 
highly presumptive that the uterus, together with the tubes and 
ovaries, has failed to develop beyond the infantile type. The 
ovaries are primarily at fault in the majority of cases, and in conse- 
quence the uterus fails to develop. While there is little encourage- 
ment in treatment of any kind it is manifestly illogical to direct the 
treatment to the uterus rather than to the ovaries — a procedure 
akin to whipping the cart to make the horse go. The complete 
closure of any portion of the genital tract will result in sterility, but 
these conditions are rare, with the exception of closure of the tubes 
from inflammatory adhesions. The influence of stenosis in causing 
sterility is doubtless exaggerated. A congenital narrowing of the 
cervical canal prevents the passage of spermatozoa, but in such 
cases there is usually an underdevelopment of the uterus, and 
possibly the ovaries as well, to account for the sterility. 

The vagina may be too short or too narrow to retain the semen, 
and the cervix may be too long to allow the entrance of the sper- 
matozoa from the vault of the vagina, where it is usually deposited. 
A short cervix jper se is not a cause for sterility; not infrequently 
the explanation lies in an underdevelopment of the uterus asso- 
ciated with a short cervix. 

A frequent cause of secondary sterility is superinvolution of the 
uterus brought about by superlactation, infection, and malnutrition. 

(c) Malpositions as direct causes of sterility have been greatly over- 
rated. Pregnancy is possible in all malpositions of the uterus with 
the exception of complete inversion. We are forced to conclude 
that the underlying cause is more often in accompanying inflam- 
matory lesions and in dyspareunia. Chronic endometritis and 
ovaritis are so commonly associated with displacements, and are 
such potent causes of sterility, it is fair to assume that they are 
most often the underlying causes. 

The displaced cervix is a more likely cause than is the displaced 
body of the uterus. The diflficulty with which the semen enters 
the cervix when displaced forward, or to the side in backward or 
lateral displacement of the uterine body, will account for sterility, 
whereas it is difficult to conceive of the cervical canal being 



48 GENERAL DIAGNOSIS 

obstructed by the flexion of the body upon the cervix. The thick, 
resisting wall of the uterus will not permit of so sharp bending as 
to obstruct the passage of spermatozoa. Reasoning a priori, an 
extreme retroversion with the cervix pointing upward and forward 
would more likely cause sterility than would an uncomplicated 
retroflexion with the cervix pointing downward and backward. 
From like reasoning, descent of the uterus, especially when asso- 
ciated with elongation of the cervix, as is usually the case, would 
be still more likely to result in sterility because of the difficulty of 
the semen gaining entrance to the cervical canal. 

(d) Traumatisms of the cervix and vagina not infrequently predis- 
pose to sterility. A lacerated perineum allows of the free escape 
of semen from the vagina, and a lacerated cervix followed by 
erosion and eversion of the cervical mucous membrane may offer 
an obstruction to the semen. Rectovaginal and vesicovaginal 
fistulse cause sterility by the effect of the urine and feces upon the 
semen, by the accompanying vaginitis and the resulting dyspa- 
reunia. Cicatricial contraction of the vagina following an injury 
may interfere with sexual union. 

(e) Pelvic inflammation is by far the most prolific source of sterility, 
and first among the various lesions is endometritis. The hyper- 
plastic form of endometritis will most certainly cause sterility, and 
particularly when associated with profuse hemorrhages and leucor- 
rhoea. The diseased endometrium is an unfavorable resting-place 
for the ovum, and the discharges play havoc with the spermatozoa. 
In the cervix the increased mucous secretions of endocervicitis plug 
the cervical canal so effectually as to prevent the entrance of the 
semen. Vulvovaginitis may prevent conception through perverted 
acid secretions and dyspareunia. Infections of the tubes destroy 
the cilia and often the epithelium as well, thereby hindering the 
progress of the ovum through the tube to the uterus. Closure of 
the fimbriated end of both tubes, resulting in a distention of the 
tube with serum, blood, or pus, will almost certainly cause permanent 
sterility. Yet it is of interest to know that pregnancy has followed 
upon the disappearance of double pyosalpinx, a fact which speaks 
for conservative treatment of salpingitis. 

A chronic inflammation or passive congestion of the ovary results 
in a hyperplasia of the connective tissue surrounding the follicles, 
in a thickening of the tunica albuginea, and in possible adhesions 



THE CLINICAL HISTORY 49 

about the ovary. All this renders difficult or impossible the escape 
of ova into the tube. 

In pelvic cellulitis and pelvic peritonitis constricting bands of 
adhesions may obstruct the lumen of the tube, and so displace the 
uterus, ovaries, and tubes as to cause sterility. An organized 
exudate about the ovary will prevent the ova escaping and lead to 
cystic degeneration of the ovary. In all these forms of infection 
dyspareunia is a large factor in the causation of sterility. 

(/) New-formations as causes of sterility are yet to be considered. 
In general, they operate through mechanical obstruction. By their 
presence an inflammatory reaction may develop as the prime cause 
of the sterility. Degeneration of the tumor leading to an irritating 
discharge acts in a deleterious manner upon the spermatozoa. The 
size of the growth is not of so much consequence as the position; a 
small fibroid in the cervical canal may cause complete obstruction, 
while pregnancy may go on to full term in subperitoneal fibroids 
of enormous size. Malignant growths rarely cause sterility, because 
the childbearing period is usually at an end before the advent of 
either carcinoma or sarcoma. Sterility associated with amenorrhoea 
in the presence of an ovarian cyst suggests the possible presence of 
a similar involvement of the other ovary. 

{g) Venereal Diseases. Gonorrhoeal infection is a potent cause 
of sterility, but it is doubtful if syphilis is often a cause of absolute 
sterility. 

THE MENOPAUSE. 

The menopause is a perfectly natural event in the advanced 
years of women, and is therefore not a cause of ill health. The 
popular idea that the ''change of life'' is a critical time in a woman's 
life-history is quite correct, but this does not imply that the men- 
opause "per se is in any way a menace to the life of a woman. It 
is a critical time because the menopause marks the beginning of 
old age, when ill health and debility would naturally be first manifest. 
There are, however, certain attending phenomena which disturb 
the comfort and general activity of previously healthy women. This 
discomfort is not ill health; that is to say, it is not to be dignified 
by the term disease. There is a disinclination to mental and 
physical exertion. The nervous and vascular systems are more or 
less disturbed. Functional heart troubles, associated with fore- 

4 



50 GENERAL DIAGNOSIS 

bodings of impending danger, are common experiences. Hot 
flashes, a sense of fulness in the head, and drowsiness are com- 
plained of. The memory fails from lack of concentration, and 
there is a marked decline in the capacity for both mental and 
physical work. 

The above are the usual experiences of healthy women living under 
favorable circumstances as they pass through the menopause. 

Premature Menopause. The menstrual floAV may be perma- 
nently checked at an early age, even so early as the twenty-fourth 
year. The causes of premature menopause are both general and 
local. The general causes are those referable to the disorders of 
the nutritive and vascular systems — i. e., primary and secondary 
anaemias and general wasting diseases. The local causes include 
the removal of the menstrual organs, also infections, degenerations, 
and new-formations of the uterus and ovaries. It is interesting to 
observe that where healthy ovaries have been removed, thereby 
bringing on the menopause abruptly, the usual derangements of 
the climacteric are exaggerated; whereas the removal of ovaries 
whose functions have been largely lost through disease causes 
little or no disturbance. 

Delayed Menopause. The menstrual periods may be continued 
far beyond the average time and without anxiety when the 
menstrual functions appear normal. When, however, the menses 
become increased in frequency and in amount it becomes imperative 
to inquire into the cause. The general and local causes of pro- 
longed morbid menstrual functions are enumerated in the section 
on Uterine Hemorrhage (page 29). Scanzoni believes that the 
prolonged menopause is often due to senile rigidity and friability 
of the uterine arteries, while Kisch ascribes them to softening and 
relaxation of the uterine tissues. Undoubtedly passive congestion 
of the pelvis from whaj;ever cause may prolong the menstrual 
period. 

In the absence of all general and local causes for hemorrhage 
from the uterus it is possible to explain the prolonged menopause 
by the existence of vasomotor changes. We must be careful to 
exclude the presence of carcinoma and all local lesions as well as 
the above-mentioned general factors before accepting such indefinite 
explanations as vasomotor changes. 

The average time of appearance of the change of life is from 



THE CLINICAL HISTOB Y 51 

forty to fifty-five years of age. The earliest recorded natural meno- 
pause began at twenty-four years of age, the latest at seventy. 
The factors influencing the time of appearance of the menopause 
are: 

1. Climate. The colder the climate the later the menopause. 

2. Social State. Sir Andrew Clark states that the menopause 
occurs earlier in the more civilized and cultured classes. 

3. Race. The Jews are said to reach the menopause at an earlier 
time than the average woman in the same climate. 

4. Heredity. It has been frequently observed that heredity has 
a determining influence upon the establishment of the menopause; 
this tendency toward an early or late menopause may persist 
through several generations. 

5. General and Local Diseases, (a) Those favoring an early 
climacteric are atrophy of the uterus and ovaries, superinvolution of 
the uterus, chronic metritis and ovaritis, postpartum hemorrhages, 
puerperal sepsis, and the general wasting diseases. (6) Those 
favoring a late climacteric are malignant growths and fibroids of 
the uterus, endometritis, subinvolution of the uterus, and chronic 
metritis. 

The climacteric has an average duration of three to four years, 
and has been known to extend over a period of twelve years. During 
this time the menstrual periods commonly recur at longer and 
longer intervals as the flow becomes more and more scant; this is 
known as the "dodging period." 

In about one woman in seven the menses stop suddenly and 
permanently. As a rule, it may be stated that an abrupt ending 
of the menstrual periods is due to some morbid condition, general 
or local. 

The clinical manifestations of the menopause are most varied. 
They are seldom wholly absent, nor are they constantly present. 
As a rule, they recur at irregular intervals. 

The general phenomena associated with the menopause are 
nervous disturbances, such as irritable temperament, despondency, 
forgetfulness, fainting, vertigo, flashes of heat and cold, perversion 
of taste, loss of sexual desire, and occasionally a homicidal or 
suicidal tendency. 

The local phenomena are atrophy of the genital organs and of 
the breasts, and in many cases an increase in the body weight. 



52 GENERAL DIAGNOSIS 

There are no facts to substantiate the statement that the develop- 
ment of skin diseases is influenced by the menopause. 

The Influence of the Menopause on Certain Morbid Con- 
ditions in the Pelvis. It will be of practical interest to inquire 
into the influence of the menopause upon certain morbid conditions 
in the pelvis. We find a certain percentage of these lesions arises 
during the climacteric, while others are aggravated or are made 
to disappear by the advent of the change of life. 

Foremost among the lesions that are prone to appear in the 
climacteric are malignant growths. Peculiar catarrhal forms of 
endometritis are known to arise at this time. Displacements of 
the uterus, and particularly prolapsus uteri, are of common occur- 
rence as the result of retrograde metamorphosis of the uterine 
supports. Fibrous polyps of the cervix are said to frequently arise 
subsequent to and during the climacteric and are the cause of 
hemorrhage — a fact confirmed by my own experience. 

Those existing conditions in the pelvis which are aggravated by 
the menopause are displacements of the uterus due to relaxation 
of the uterine supports. A descensus becomes converted into a 
complete prolapsus as the uterine supports relax after the meno- 
pause. 

On the other hand, the menstrual disturbances and pressure 
symptoms incident to displacements of the uterus and its append- 
ages are relieved by the suspension of menstruation and diminution 
in the size of the uterus. Fibroids of the uterus very often cease 
to grow, and not infrequently decrease in size. This is particularly 
true of interstitial fibroids. While we may hope for favorable 
changes in uterine fibroids at the climacteric, we are to remember 
that the fibroid may be transformed into a sarcoma. (See p. 310.) 
The influence of the menopause upon existing ovarian cysts is not 
clearly understood. We learn from the statistics of Olshausen and 
others that cysts of the ovary arise more often during the period 
of sexual maturity and with far less frequency after the climacteric. 
The "involuted shrunken cysts" of Rokitansky are often the direct 
result of the menopause, though perhaps they more often follow 
upon the twisting of the pedicle. Fatty degeneration of the cyst 
wall is especially prone to occur during and after the menopause, 
and this suggests the most probable cause of spontaneous rupture 
of ovarian cysts at this time. 



THE CLINICAL HISTORY 53 

LEUCORRHCEA. 

Normal Secretions of the Genital Organs. 

Leucorrhcea in Infants. 

Leucorrhoea in Virgins. 

Leucorrhcea in the Period of Sexual Maturity. 

Leucorrhcea in Old Women. 

Any discharge from the vulva that is not blood is popularly 
called *' whites" or leucorrhoea. When the secretion departs from 
the normal in color, consistency, odor, irritability, and amount, 
there must exist either a functional or an organic lesion of the 
genital organs. It is of the greatest importance to determine the 
character and source of the secretion. 

The Normal Secretions of the Genital Organs are: I. From the 
vulva the ordinary secretions of sebaceous and sweat glands. The 
Bartholinean glands lying in the labia majora secrete mucus, 
particularly during sexual excitement. The reaction is alkaline, 
and the amount is scarcely noticeable. 

2. The vagina does not ordinarily contain glands, but occasion- 
ally a few are found in the vault of the vagina. The vagina has 
essentially a skin surface, having no secretion under normal con- 
ditions. The so-called vaginal secretion is the accumulated outpour 
of the uterine body and cervix mixed with epithelium and bacteria. 
The secretion is acid in reaction as the result of the action of certain 
bacteria changing the alkaline secretion of the uterus to an acid 
reaction. 

3. The secretion of the cervix is mucus. It is tenacious and 
alkaline in reaction. 

4. The secretion of the endometrium is serous and sufficient in 
amount to moisten the surface; it is alkaline, clear, and transparent. 

For clinical purposes we will consider leucorrhcea as it occurs in 
the various periods of life. 

Leucorrhoea in Infants. In children a leueorrhoeal discharge 
seldom arises from a point above the hymen. As a rule it is the 
expression of a vulvitis, which in turn is caused by soiled diapers, 
intestinal worms, highly acid urine, gonorrhoea, masturbation, and 
the strumous diathesis. The vulva appears swollen and reddened, 
is tender, and is covered by a slimy secretion. 



54 GENERAL DIAGNOSIS 

Leucorrhoea in Virgins. In young girls it is not unusual for a 
transient leucorrhoea to appear from time to time. No pathological 
basis for the leucorrhoea can be discovered further than a possible 
pelvic congestion. Persistent leucorrhoea may be due to the same 
causes found in childhood. As in infants, the lesion is commonly 
a vulvitis, and is rarely found above the hymen. The secretion is 
seldom suflScient to more than moisten the vulva, and rarely calls 
for a local examination. Ansemia is always to be considered in 
determining the contributing factors. 

Leucorrhoea in the Period of Sexual Maturity. The secretion 
may come from any portion of the genital tract — from the vulva, 
vagina, cervix, body, and tubes. In the vast majority of cases the 
cause may be ascribed to gonorrhoea and to labor and abortion. 
The most profuse leucorrhoea is occasioned by gonorrhoeal infec- 
tion. In addition to these causes may be mentioned instrumental 
and digital inspection, displacements of the uterus, passive con- 
gestion due to an interference with the return supply of blood 
from diseases of the heart, lungs, liver, kidney, and spleen, and 
also to abdominal tumors, to acute infectious diseases, and to all 
benign and malignant new-formations of the vulva, vagina, and 
uterus. 

Not only the cause but the source of the secretion must be deter- 
mined. Schultze devised the following method of demonstrating 
the source of the secretion: Following a vaginal douche of sterile 
water a large tampon of sterile absorbent cotton is placed against 
the cervix and left there for several hours. If the secretion comes 
from the uterus, it will collect upon the top of the tampon and can 
be examined for bacteria and other elements. If the secretion is 
mucus and in small amount, it must come from the cervix; if 
watery and abundant, it comes from the body of the uterus, rarely 
from the tubes — "hydrosalpinx profluens." 

It is of importance to distinguish between a hypersecretion of 
the endometrium and a discharge due to some pathological lesion. 
This is often difficult, and may be impossible. Women will often 
complain of a leucorrhoea immediately preceding and following 
the menstrual flow. As a result of the congestion which precedes 
the monthly flow one or more days and continues a variable time 
after the cessation of the bloody flow, there is a hypersecretion of 
the glands sufficient to give rise to a seromucous discharge. 



THE CLINICAL HISTORY 55 

Leucorrhoea in Old Women. In the aged leucorrhoea has a 
more serious significance. The source is the vulva, vagina, and 
uterus. Senile vaginitis, vulvitis, and endometritis are the most 
common causes. 

In the case of all unusual discharges from the genital tract of 
women advanced in years, whether the discharge be watery, bloody, 
purulent, or ichorous, there is always a suspicion of malignancy, 
and this thought is uppermost in the search for the underlying 
cause. Gonorrhoea infecting the aged rarely involves the uterus 
and tubes. The infection is generally limited to the vagina and. 
urethra. The irritation of a filthy and ill-fitting pessary will occasion 
a vaginal discharge. 

Malignant growths give at first a watery discharge, which later 
becomes turbid, bloody, and foul-smelling. Cancer of the body of 
the uterus is more common after the menopause than is cancer of 
the cervix; therefore, in seeking the cause of a suspicious discharge 
occurring after the menopause it may be necessary to explore the 
uterine cavity with a curette. The discharge of a senile endo- 
metritis may simulate that of a malignant growth, and nothing 
short of an exploratory curettage with a microscopic examination 
of the scrapings will establish the diagnosis. 



CHAPTEE II. 

PHYSICAL EXAMINATION. 

Preliminary Measures. Having taken the history as outUned 
in the previous chapter, the next step is to determine by a general 
physical examination the possible bearing which some remote affec- 
tion may have upon the pelvic organs. 

Confining ourselves more particularly to the abdomen and pelvis, 
we will proceed to outline the method to be employed in a systematic 
and thorough physical examination, and will describe the methods 
in the order in which practical experience has sanctioned their 
usage. 

No invariable order can be adopted; circumstances will alter the 
general routine; but it is well to follow a definite method of pro- 
cedure as closely as possible. The habit of making a systematic 
routine examination will not infrequently eliminate many errors 
in diagnosis. The examiner will not likely be content with the 
finding of any single explanation for the patient's complaint, but 
will seek farther for other possible lesions. The writer recalls a 
case in which hemorrhage was the symptom complained of. On 
physical examination an interstitial fibroid was discovered. This 
was believed to explain the hemorrhage, and a hysterectomy was 
performed. In the cavity of the uterus was a cauliflower car- 
cinoma, which had not been suspected. The examination had not 
been complete; when a single cause for the hemorrhage was dis- 
covered no further search was made. Had a more conservative 
operation been performed and the uterus not removed, the more 
serious of the lesions would have been overlooked. Such experiences 
teach us that we are not to be content with the finding of a single 
cause for a given symptom, but are to search for all possible causes, 
inasmuch as two or more morbid conditions may contribute to the 
symptom. 

In making a physical examination care should be taken for fear 
of injury to the structure examined; and the examiner will always 
( 56 ) 



PHYSICAL EXAMINATION 



57 



endeavor to avoid inflicting pain. The more skilled the examiner 
the more careful and gentle he will be. A vaginal examination 
may cause great discomfort, and serious damage may be done to 
an inflamed mucous membrane and malignant growths. As the 
result of a bimanual examination roughly made, not only much 
suffering may be caused, but cysts may be ruptured, abscesses may 
break into the peritoneal cavity, the gestation sac of an ectopic 
pregnancy may burst, adhesions may be torn, and in the use of the 
sound, curette, and speculum, serious and even fatal injuries may 



Fig. 1 




Examining table. (Schmidt.) 



be sustained. While an exact diagnosis is desired in the first 
examination, it is seldom absolutely necessary and is frequently 
impossible. Certain procedures, such as catheterizing the uterus, 
must often be postponed for a subsequent examination. 

It is seldom necessary to make an examination during the men- 
strual period. It is not only objectionable to the patient, but at this 
time the pelvic viscera are congested, and there is an added risk 
of injury. During the menstrual period the cervix is softened and 
somewhat patulous, and for this reason Simpson has advised the 



58 GENERAL DIAGNOSIS 

exploration of the uterine cavity during menstruation for the detec- 
tion of foreign growths. The added risk of infection and injury 
would seem to contraindicate such a practice. 

We therefore elect the intermenstrual period for local examina- 
tions and treatments, for the reasons that the conditions then found 
are more nearly normal and there is less risk of injury. Further- 
more, it is best to make the examination at a time when the patient 
is in a condition the nearest possible to the normal. To this end 
the examination should not be made immediately after a full meal, 
or when for any reason the patient is exhausted and nervous. 

Whenever possible the patient should be examined on a table 
with good light. Whatever the table used it should be of convenient 
width and length to permit the patient to assume any desired posi- 
tion. It should be so placed as to be approached by the examiner 
from all sides, and should be of convenient height to allow him 
to proceed without assuming an unnatural and strained attitude. 

Fig. 1 shows a correct table for the making of examinations 
and operations. This table was designed by Dr. L. E. Schmidt, of 
Chicago, and has the special advantage of directing the buttocks 
well over the edge of the table, thereby favoring instrumental 
examinations of the bladder, vagina, and rectum. 

We are often obliged to examine a patient on a bed or couch. 
The author does not favor the examining chair because of its 
formidable appearance, its cumbersome weight, and the incon- 
venience with which the position of the patient is changed. 



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CHAPTEE III. 

EXTERNAL ABDOMINAL EXAMINATION. INSPECTION OF 

THE ABDOMEN. 

It is well to expose the abdomen by removing the corset and all 
constriction about the waist. A sheet should cover the upper portion 
of the trunk to the waist line; another sheet should cover the lower 
extremities and hips, as seen in the accompanying illustrations. 

The chief value of inspection is to determine abnormalities in the 
contour of the abdomen. We are to observe the size of the 
abdomen, its form, the site of a convexity or depression, the laxity 
or tension of the abdominal wall, the retraction or distention of the 
umbilicus, the presence of linea albicantes, pigmentations, distended 
veins, hernia, skin diseases, peristaltic movements of the intestine, 
pulsations of the aorta as seen through the thin abdominal wall, 
and fetal and respiratory movements. Variations in the contour of 
the abdomen produced by tympany, ascitic fluid, tumors, and thick 
parietes are readily recognized by a competent observer. 

In a thick, fatty abdominal wall the abdomen is flattened and the 
flanks protrude and sag downward when the patient lies on her 
back. Great transverse folds are formed. (See Plate IV.) 

Free ascites with the patient in the dorsal position causes a bulg- 
ing in the flanks and a flattening of the anterior abdominal wall. 
With change in position of the patient the contour of the abdomen 
is altered. (See Plate V.) 

In ovarian cysts the abdomen is irregularly ovoid. In the very 
large cysts, or where the pedicle is long and the cyst is freely mov- 
able, the abdomen may be evenly distended. When the abdominal 
wall is thin and the cyst large and multilocular, it is sometimes 
possible to see the irregular elevations through the abdominal wall. 
(See Plate VI.) 

Large uterine fibroids may evenly distend the abdomen, but more 
frequently cause an irregular protuberance. (See Plates VII. and 
VIII.) In interstitial fibroids the abdominal enlargement is 
inclined to be more median than in ovarian cysts. (See Plate VII.) 

In excessive distention of the abdomen the skin is white and 

shiny, and often streaked with irregular red lines. 

(59) 



CHAPTEE IV. 

PALPATION OF THE ABDOMEN. 

The abdomen is best palpated with the patient in the dorsal 
position. The head and chest if elevated will diminish the field of 
exploration. When it is desired to note the effect of change in 
position upon the abdominal contents, the erect, the knee-elbow, or 
the lateral position may be assumed. 

Preliminary to all abdominal and pelvic examinations the bladder 
and rectum must be empty and all constricting bands of clothing 
removed. The examiner's hands should be warm and the finger- 
nails cut short. Both hands should be used. They should be laid 
gently upon the abdomen, the pressure steady and firm, avoiding 
all sudden and unexpected movements. The patient should be 
instructed to breathe quietly, with the mouth open. Her attention 
may be drawn from the examination by asking questions concern- 
ing some other portion of her body. In this manner, with thin 
and relaxed abdominal walls, it may be possible to palpate the 
projecting vertebrae, the posterior wall of the pelvis, the promontory 
of the sacrum, and the pulsating aorta. 

Thick and tense abdominal walls may prevent satisfactory 
palpation of the abdomen, thereby necessitating an anaesthetic. 
Very often by care and patience the tendency to contract the 
abdominal walls may be overcome without resorting to anaesthesia. 
Remember, that it is possible to do harm by rupturing collections 
of blood, cysts, and abscesses, and by exciting a limited or latent 
inflammation. 

For convenience of description the abdomen may be divided 
into quadrants (Fig. 2). These are named respectively the right 
upper, the left upper, the right lower, and the left lower quadrants. 

Before determining the nature of a swelling, it is necessary to 
identify it either as growing from the pelvis or from the abdomen, 
and to demonstrate its relation to the viscera and the abdominal 
wall. 

(60) 



PALPATION OF THE ABDOMEN 



61 



It is well to follow a routine system, beginning below and pro- 
ceeding upward. If the preliminary step of emptying the bladder 
and bowels is taken there should be no confusion with a fecal tumor 
and distended bladder. Sensitiveness, tension, thickness, and con- 
sistency of the abdominal wall are noted by systematically palpating 
symmetrical parts and comparing them. No considerable pressure 



Fig. 2 



M 




Upper Right 
Quadrant 



Lower Right 
Quadrant 




Lowr ]J 
duadrant 





Diagram of the areas into which the abdomen may be divided. 



need be exerted in determining these facts. When sensitiveness is 
determined we are to carefully distinguish between nervous irri- 
tability and inflammation. When deep pressure is tolerated in the 
presence of superficial tenderness, inflammation can be almost 
surely excluded. All tumors of the abdominal wall move with the 
wall, and may be lifted up with it. The connection of a tumor 



62 GENERAL DIAGNOSIS 

with the skin is recognized by inabihty to Uft the skin apart from 
the tumor. 

All intraperitoneal organs and viscera move with respiration; 
the nearer the diaphragm the greater the excursion. If the organ 
or tumor is adherent or is incarcerated the excursions will be 
limited. These isochronous respiratory movements are readily 
recognized by the hand, and under favorable conditions may be 
recognized by inspection. An organ or tumor lying underneath 
the peritoneum, if protruding into the peritoneal cavity, may be 
affected by respiratory movements. Such, for example, is the case 
with a movable kidney and a pedunculated subserous fibroid. All 
tumors arising in the pelvis tend to grow upward. 

The contour of the swelling and its consistency are determined 
by palpation. It is important to recognize periodical alterations 
in consistency in connection with the differential diagnosis between 
pelvic and abdominal swellings and a pregnant uterus. No swell- 
ing other than a pregnant uterus contracts intermittently. The 
softening of a tumor speaks for a degenerative process. When the 
swelling is deep-seated or the abdominal wall thick and tense, it 
may be impossible to determine the consistency and contour of the 
swelling. Fluctuation is best detected by percussion associated 
with palpation, and when elicited speaks for the presence of .fluid. 
According to the readiness of response to impulse, we may judge to 
some extent of the consistency of the fluid. The examiner is often 
at a loss to decide whether or not fluid is present. Tense cysts 
may not fluctuate, and, on the other hand, soft tumors may appear 
to fluctuate. 

The connection of the swelling with other tumors and viscera 
may be determined by palpation. The exact location of the tumor 
is noted, and by palpation is often traced to a particular organ. 
By changing the position of the patient we may gain additional 
information regarding the attachment of the swelling. Spencer 
Wells has pointed out that non-adherent pedunculated tumors of 
the pelvis gravitate into the abdominal cavity when the knee-chest 
position is assumed. 



CHAPTEE V. 

PERCUSSION OF THE ABDOMEN. 

The abdomen is best percussed with the patient in the dorsal 
position. When it is desired to demonstrate by percussion the 
change in position of a tumor or fluid the patient may assume 
any required position. 

Since the normal percussion tone of the abdomen differs accord- 
ing to the contents of the stomach and bowels, the results obtained 
by percussion are not altogether reliable. The normal range of 
motion in the abdominal and pelvic viscera also adds to the un- 
certainty of the conclusions arrived at by percussion. Furthermore, 
we cannot compare the percussion note on corresponding sides, as 
is done in percussing the chest. Percussion is to be regarded as 
an auxiliary to palpation. 

In proceeding it is well to go over the entire abdomen in a system- 
atic manner. If firm pressure is made by the fingers the intestines, 
unless adherent, will be pushed aside, and the underlying organ 
or tumor can be directly percussed. Percussion is of the greatest 
value in demonstrating the presence or absence of intestine lying 
in front of the organ or tumor. All other conditions are better 
elicited by palpation. 

By reference to the diagram in Fig. 186 it will be seen that in 
ascites the dull percussion note of the fluid is found in the most 
dependent portion of the abdomen, and the tympanitic note of the 
intestine is found above the fluid. Where the mesentery is short 
or the bowel fixed by adhesions, the above findings are not elicited. 
If gas does not distend the intestine, or if fecal matter fills the 
intestine, the tympanitic note is not elicited in contrast to the dull 
note of the fluid. Where the ascitic fluid greatly distends the 
abdomen there may be no change in the area of dulness. Where 
there is a small amount of ascitic fluid the intestine may float to 
the side of the abdomen and give a tympanitic note together with 
fluctuation. 

When an ovarian cyst (Fig. 187) distends the abdomen the per- 
cussion note is dull in front and the tympanitic note of the intestine 

is found low in the flanks. 

(63) 



CHAPTEK VI. 

AUSCULTATION AND MENSUKATION OF THE ABDOMEN. 

Auscultation is of little value except in the diagnosis of preg- 
nancy. Other than the sounds referable to the foetus, the placenta, 
and the pregnant uterus, there may be heard over the abdomen the 
maternal heart tones, pulsations of the aorta, murmurs of abdom- 
inal aneurisms, gurgling of gas in the bowel and stomach, and the 
friction sounds caused by the rubbing together of rough surfaces. 

The patient should be in the dorsal position, with the legs suffi- 
ciently flexed to relax the abdominal walls, yet not to the extent 
of interfering with the examination. The ear or stethoscope may 
be employed, preferably the latter. 

The uterine bruit is not to be mistaken for the bruit that is heard 
in about 50 per cent, of uterine tumors and occasionally in ovarian 
cysts. A similar bruit has been heard over the tumors of the liver, 
spleen, and the retroperitoneal spaces. No such sound has been 
heard over tumors of the kidney. 

Mensuration is of some importance in the diagnosis of abdominal 
swellings. It finds its greatest service in obstetric practice. It is 
a fairly precise means of determining the rate of growth of an 
abdominal swelling. 

Exact rneasurements are difficult, because of the variable degree 
of distention of the intestine and the shifting of the abdominal 
tumor. There must be a convexity of the abdomen; otherwise, 
comparative measurements would be of no value. 

An ordinary tape-measure will answer the purpose. The measure- 
ments to be taken are : the greatest circumference, the circumference 
at the level of the umbilicus, the distance from the ensiform cartilage 
to the pubis, from the umbilicus to the anterior superior spine of 
the ilium on either side, and the distance from the linea alba to the 
spine of the vertebrse. It is important for the purpose of com- 
parison that the same position be assumed in making subsequent 
measurements. 
(64) 



CHAPTEE VII. 

EXAMINATION OF THE EXTERNAL GENITALS. 

Digital Examination of the Internal Genitals. 
Digital Examination of the Vagina. 
Combined Vaginal Examination. 
Abdominovaginal Examination. 
Digital Examination of the Rectum. 
Digital Examination of the Bladder. 
Pelvimetry. 

The routine practice of inspecting the external genitals is 
unnecessary, and should be discountenanced. When required the 
Sims position or the ordinary lithotomy position is assumed. The 
sheet is drawn about the lower extremities and tucked about the 
vulva in such a manner as to make the least possible exposure. 
The labia are held apart by the thumb and index finger for the 
inspection of the vestibule, urethral opening, hymen, and perineum. 

When gonorrhoea is suspected the urethra and Bartholinean 
glands should be inspected. When these structures are infected, 
and particularly if pus can be expressed from the urethra, the diag- 
nosis of gonorrhoeal infection amounts to a moral certainty. 

Recent injuries should be inspected, but long-standing injuries 
to the pelvic floor can be detected and a fair estimate of their extent 
gained from the sense of touch alone. 

Malformations, pigmentations, varix, oedema, and all the new- 
formations should be examined by direct inspection. 

DIGITAL EXAMINATION OF THE INTERNAL GENITALS. 

The hidden position of the internal genitals makes it necessary 
to examine them through one or more of the natural openings — 
i. e.j rectum, bladder, and vagina. Until the end of the eighteenth 
century the vaginal route was the only one used for such exami- 

5 ( 65 ) 



6Q 



GENERAL DIAGNOSIS 



nations. Little progress was made in the diagnosis of diseases of 
the internal genital organs until the introduction of combined 
methods of examination were introduced by M. Puzos, in the 
eighteenth century, . and revived and elaborated by Sir James Y. 
Simpson. 

By the combined examination we have the only means of deter- 
mining the size, position, consistency, mobility, sensitiveness, and 
relations to the pelvic organs. 

Digital Examination of the Vagina. This is made with the 
patient in the Sims or lithotomy position, rarely in the erect or 
knee-chest position. When the bare hand is used it should be 
scrubbed with soap and water and disinfected with lysol. The 
most elegant lubricant for the examining finger is scented green 



Fig. 3 




FULL SIZE 



soap. Vaselin is not desirable, because of the odor from the 
secretions, which clings to the fingers in spite of vigorous scrubbing. 
In an ordinary digital examination of the vagina it is unnecessary 
to expose the vulva; the examination may be made in a perfectly 
satisfactory manner under cover of a sheet. 

It should be the invariable practice of physicians to wear a thin 
rubber glove or finger-cot (Fig. 3) in making vaginal and rectal 
examinations. This is done not only as a matter of cleanliness 
in preventing septic infection of the genital organs, but as well to 
prevent infection of the examining finger. A well-known authority 



EXAMINATION OF THE INTERNAL GENITALS 



67 



on skin and veneral diseases informed me that an average of one 
physician a week came to his office with a syphihtic infection 
acquired in making examinations. This appaUing statement should 
make us very cautious. 



Fig. 4 




Combined vaginal examination. 



The attitude of the examiner should be carefully considered. 
Fig. 4 shows the correct position, though the table is somewhat 
high for convenience and efficiency. The examiner stands at the 



68 



GENERAL DIAGNOSIS 



end of the table; one foot rests upon a low stool; the elbow of the 
examining arm rests upon the knee, thereby permitting free motion 
in the forearm and hand. 



Fig, 5 




Lithotomy position. 



Fig. 6 




Knee-chest position. 



The choice of hand will depend in part upon the comparative 
utility of the two hands, but more upon the habit acquired. As a 
general thing, the right side of the pelvis is best palpated with the 



EXAMINATION OF THE INTERNAL GENITALS 



69 



Fig. 7 



right hand, and the left side with the left hand. In the early 
experience of the examiner it is best to cultivate the sense of touch 
in a single hand, and in later years, as there are opportunities for 
more experience, either hand may be used, with equal expertness. 

Shall One or Two Fingers Be Used in Digital Examinations of the 
Vagina? Where two fingers can be introduced without discomfort 
to the patient, the two will be found more effective than one. In 
order that the fingers may be in- 
troduced with the least possible 
annoyance to the patient, the labia 
are separated by the thumb and 
index finger. The middle finger 
of the opposite hand is inserted 
into the vulvar opening, with the 
palmar surface resting upon the 
perineum. Firm pressure is made 
by the finger upon the perineum. 
The vulvar outlet is thereby deep- 
ened, and into it the index finger 
can be readily inserted. The two 
fingers are now passed into the 
vagina, making firm pressure upon 
the perineum and avoiding press- 
ure upon the clitoris and urethra. 
When the fingers are fully inserted 
the palm of the hand is turned 
upward. When the vulvar outlet 
is small, the mucosa sensitive or 
the hymen intact, a single finger 
should be employed. Where pain 
is caused by inserting the finger, 
it is well to ask the patient to bear 
down while the examination is 
being made. 

The following conditions are determined by a simple vaginal 
examination: the size, form, and position of the vulva, vagina, 
and vaginal portion of the cervix; the condition of the hymen, 
whether present or absent, perforate or imperforate; the integrity 
of the pelvic floor; the presence of new-growths in the vulva, 




Erect position. 



70 GENERAL DIAGNOSIS 

vagina, and vaginal portion of the cervix; sensitiveness and fulness 
in the vault of the vagina and the capacity of the pelvic outlet. 

The knee-chest position is especially used when it is desired to 
do away with intra-abdominal pressure for the purpose of per- 
mitting the uterus and freely movable pelvic tumors to rise out of 
the small pelvis. 

The erect position is practised chiefly in determining the degree 
of prolapsus of the uterus. 

After concluding the examination the finger is withdrawn and 
the secretion on the finger inspected. 

The Combined Vaginal Examination (Bimanual). The advan- 
tages of a combined examination over a simple vaginal or rectal 
examination are evident. The combined method may be regarded 
as the most valuable of all physical explorations of the pelvis. 
Various combinations may be utilized, they being designated as 
abdominovaginal, abdominorectal, abdominovesical, abdomino- 
vesico vaginal, abdominovesico, and rectovaginal. 

As preliminary steps to the examination, the bladder and rectum 
are emptied, all clothing is made loose about the waist, and the 
patient placed in thg lithotomy position. 

Abdominovaginal Examination. In order that this method of 
examination be properly performed, the vagina must be patent and 
its walls relaxed. Furthermore, it is essential that the abdominal 
walls be suflSciently thin and relaxed to permit of depression. Where 
there is much fat in the abdominal wall, a pendulous abdomen, 
or tenderness and pain on pressure, little or nothing can be accom- 
plished by this method without the aid of an anaesthetic. In 
extreme elongation of the vagina, and when there is an excessive 
deposit of fat in the external genitals and thighs, it may be impos- 
sible to palpate high in the vault of the vagina. 

The bimanual examination is best performed in the lithotomy 
or dorsal position, with the thighs slightly flexed. Little can be 
gained from such an examination with the patient in the erect or 
knee-chest position. The side positions, while awkward and ill- 
adapted for general use, are of special service in testing the mobility 
of the pelvic viscera and tumors. 

All that has been said in describing the digital examination of the 
vagina concerning the choice of hands, the use of one or two fingers, 
and the manner of introduction of the fingers, will apply to the 



EXAMINATION OF THE INTERNAL GENITALS 



71 



combined method of examination. The function of the hand upon 
the abdomen is to steady the pelvic organs while being palpated by 
the fingers in the vagina. A complete outlining of the pelvic viscera 
by the external hand is not possible, consequently light pressure 



Fig. 8 




Back view of Sims' position. 



is all that is required, and has the advantage of not exciting the 
abdominal muscles to contract. The tips of the fingers are directed 
toward the ensiform cartilage and gradually •made to compress 
the abdominal wall at a variable point above the symphysis pubis. 



Fig. 9 




Front view of Sims' position. 



With a thin, flaccid, abdominal wall, and in the absence of large 
sweUings, the external and internal fingers may be approximated 
in front of the uterus with only the vaginal wall, the bladder, and 
the abdominal wall intervening. Under most favorable conditions 



72 



GENERAL DIAGNOSIS 



the fingers may be similarly approximated behind the uterus. 
Lifting the uterus forward and upward by the finger in the vagina, 
the uterus may be palpated over the entire surface of its body, and 
at the same time the vaginal and supravaginal surface of the cervix 
may be outlined by the finger in the vagina. In anteversion of 
the uterus, the anterior surface of the uterine body is best palpated 
by the finger in the vagina, and the posterior surface by the external 
fingers. In retroversioflexion the posterior surface of the uterus 



Fig. 10 




Abdominovaginal examination. 

is best palpated by the finger in the vagina and the anterior surface 
by the external fingers. When the uterine body is enlarged it may 
be readily outlined in the conjoined examination without elevating 
the uterus by pressure from below. 

Under favorable conditions it is possible to determine the position 
of the uterus, its size, form, sensitiveness, consistency, and mobility. 

No manipulating should be done until the position of the uterus 
is determined, and this is largely accomplished by vaginal touch. 



EXAMINATION OF THE INTERNAL GENITALS 73 

Pressure by the examining fingers may correct or exaggerate a 
malposition of the uterus. A prehminary vaginal examination will 
serve to eliminate such errors. For details of the method of exami- 
nation in displacements of the uterus see Chapter XXIII. 

The Fallopian tubes, under ordinary conditions of health, cannot 
be palpated in a combined examination. With conditions most 
favorable, in which the abdominal walls are thin and relaxed, the 
vaginal walls distensible, and the tubes in their normal position, it 
is possible to palpate the normal tubes; they are then felt as thin, 
round cords which roll between the examining fingers. 

The normal ovaries are palpated with difficulty, and are recog- 
nized by their position, size, form, and sensitiveness. The ovarian 
ligament is seldom felt. 

The pelvic peritoneum and cellular tissue should be explored as 
far as possible to discover undue sensitiveness, cicatricial contrac- 
tions, inflammatory exudates, tumor formations, and collections of 
blood. 

The rectum on its anterior wall may be explored through the 
vagina and something learned of its sensitiveness, inflammatory 
infiltrations, foreign growths, and fistulous openings. More satis- 
factory is the rectovaginal method of examination. 

The base of the bladder may be palpated through the anterior 
vaginal wall. Tumors, calculi, inflammatory infiltrations, new- 
growths, and tenderness from whatever cause can be determined 
with some degree of satisfaction. 

A rough estimate of the capacity and deformity of the bony 
pelvis can be made by the combined method. 

The abdominovaginal examination is of greatest service in the 
differential diagnosis of pelvic tumors. By the combined method 
their size, form, consistency, rate of growth, relative position, 
mobility, and relation to other structures are determined. When 
the tumor is large and in the abdominal cavity the method of 
Schultze may be employed with advantage. In addition to the 
customary bimanual examination an assistant draws the abdominal 
tumor upward while traction is made upon the cervix with a vul- 
sellum forceps. (See Plate X.) 

The tumor may so closely press upon the uterus or be so closely 
adherent to it that a line of distinction between the two cannot be 
recognized by the examining finger. The variations in consistency 



74 GENERAL DIAGNOSIS 

and form, together with the use of the uterine sound, may deter- 
mine the relations. ^Swelhngs of the tubes and ovaries are at first 
to be differentiated from the uterus; but later, as they increase in 
size and become displaced behind or to the side of the uterus, they 
may be recognized with difficulty. Likewise pelvic exudates may 
intimately blend with the uterus. Frequently bodies apparently 
immovable in one position may be movable in another. 

Examination under narcosis has many advantages. Kelly lays 
down the following rules for the use of anaesthesia in the diagnosis 
of diseases of women: 

1. Where doubt exists after the ordinary bimanual examination. 

2. Where a patient comes to a specialist after having had treat- 
ment for a long time at other hands without improvement. 

3. In all cases of pelvic peritonitis involving on^ or both ovaries 
or tubes without producing any gross tumor, the use of the anaes- 
thetic is to find out the extent of the disease. 

4. Always in unmarried women. 

Nitrous oxide will serve admirably in the majority of cases. 
When the examination must be prolonged, as in the use of the 
cystoscope or curette, either chloroform or ether should be used. 

It should he a rule to which there are no exceptions, that after the 
patient is asleep and before the operation is begun a thorough bimanual 
examination should be made. 

Under anaesthesia a higher reach may be gained by invaginating 
the pelvic floor. This is accomplished by making firm pressure upon 
the vulva and perineum with the examining hand. In so doing a 
gain of one to two and a half inches may be made. Additional 
pressure may be made by supporting the elbow of the examining 
arm against the hip and throwing the weight of the body against 
the arm. 

Digital Examination of the Rectum. In point of eflScacy, 
digital examination of the rectum and, through the rectum, of the 
pelvic structures ranks next to the vaginal method, and in some 
conditions is to be preferred. In all difficult and obscure vaginal 
examinations a rectal or rectovaginal examination should be made. 

(a) The Simple Rectal Touch. When for any reason a digital 
examination of the vulva cannot or should not be made, the internal 
genital organs must be examined per rectum. Such conditions are 
a congenital or acquired absence of the vagina, a narrow, shallow 



EXAMINATION OF THE INTERNAL GENITALS 



75 



vagina, inversion of the uterus, vaginismus, and virgins with an 
intact hymen. A rectal examination is of special advantage not 
only when the vaginal examination is precluded, but in all lesions 
in the rectovaginal space lying on the posterior pelvic wall. 

The position of the patient should be the lithotomy, knee-elbow, 
or the Sims. One or two fingers and, under anaesthesia, the whole 
hand may be used. In passing the finger into the rectum the 



Fig. 11 




Abdominorectal examination. 



tonicity of the sphincter is noted. Fissures, polyps, hemorrhoids, 
and new-formations are detected. Through the anterior wall of 
the rectum are felt the posterior vaginal wall, the cervix, and part 
or all of the posterior surface of the uterus, the base of the broad 
ligaments, frequently the tubes and ovaries when enlarged and 
prolapsed, and the uterosacral ligaments. Through the posterior 
wall of the rectum are felt the sacrum and coccyx. Because of the 
thinner and more distensible bowel wall, the structures occupying 



76 



GENERAL DIAGNOSIS 



the posterior segment of the uterus are more easily reached through 
the rectum than through the posterior vaginal vault. The cervix 
projecting backward is not to be mistaken for the body of the 
uterus. 

(b) Abdominorectal examination (bimanual) is a method carried 
out in general as is the abdominovaginal examination. In virgins 
with an intact hymen it is the method of choice. All conditions 



Fig. 12 




Eectal examination with traction upon the cervix by a vulsella forceps. 



recognized by a simple vaginal examination are more clearly 
palpated by the combined method. 

The examination may be embarrassed by coils of intestine 
wedged into the cul-de-sac of Douglas. Where such difficulties 
exist and the bowels are not adherent, they may be displaced by 
placing the patient in the knee-chest position. A Sims speculum 
is inserted into the bowel, allowing the air to rush in and balloon 
the rectum, when the bowel will fall forward out of the cul-de-sac. 



1 



EXAMINATION OF THE INTERNAL GENITALS 



77 



The patient is then placed in the dorsal position and the exami- 
nation continued. 

Traction upon the uterus in the abdominorectal exami- 
nation by vulsella forceps will greatly facilitate the examination 
where the uterus lies either too far forward or too high to be readily 
reached by the finger in the rectum. At the same time pressure 
may be made from above downward and backward upon the uterus. 



Fig. 13 




Abdomiiiovaginoreetal examination. The right hand depresses the abdomen, the thumb 
of the left hand is inserted into the vagina, and the index finger into the rectum. 



The vulsella forceps are held by an assistant while the operator 
makes the examination. No great amount of force should be 
applied to the uterus for fear of tearing adhesions. 

(c) Abdominovaginorectal examinations are seldom called for. 
While effective, they are unpleasant to patient and physician. 
The finger should never be withdrawn from the vagina and inserted 
into the rectum without cleansing. 



78 



GENERAL BIAGNOSIS 



Digital examination of the bladder, either simple or combined 
with vaginal and abdominal methods (abdominovesical, abdomino- 
yesicovaginal), will not be considered. The method has been 
replaced by other more efficient and less objectionable. 

Pelvimetry. It is seldom that pelvic measurements are taken 
of a gynecological case. This is but an evidence of the illogical 
separation of obstetrics and gynecology. Not a few of the pelvic 



Fig. U 




Vesicorectal examination. A sound is passed into the bladder and the index finger into 
the rectum. In this manner the presence or absence of the uterus is determined. 



lesions are the result of deformities of the bony pelvis. For a 
detailed description of the deformities of the pelvis and their 
measurements see text-books on obstetrics. For practical purposes 
the measurements between the anterior superior spines of the ilium, 
between the trochanters, between the widest points in the crest of 
the ilium, and Baudelocque's diameters are all that are required. 



CHAPTEE VIII. 

THE VAGINAL SPECULUM. 

For direct inspection of the vagina the speculum is used both in 
diagnosis and treatment. For diagnostic purposes it has a hmited 
field of usefulness; digital exploration will alone serve the purpose 
in a large proportion of cases. 

The lithotomy position is the one of choice. The rectum and 
bladder must be emptied. Before introducing the speculum a 
digital examination of the vagina should be made to locate the 
cervix for the purpose of knowing the proper direction in which to 
direct the speculum in exposing the cervix. 

The varieties of specula in common use are the Sims, Simons, 
bivalve, and tubular. 

Sims' speculum is used with best advantage in the lateral position 
of Sims. The vaginal outlet is spread open by the thumb and 
index finger of the left hand, while the right hand introduces the 
speculum. The blade is passed between the fingers spreading the 
vulva, and is allowed to glide over the perineum into the vault of 
the vagina. With the placing of the speculum the air rushes into the 
vagina and balloons it. In this manner a direct inspection of the 
vaginal mucosa is made possible. Firm and steady traction is made 
backward upon the perineum in exposing the cervix. The Sims 
speculum was originally used in the knee-elbow position, but is now 
almost invariably used in the Sims or left lateral posture. 

When the vagina is deep and the walls relaxed, in addition to 
the speculum, it is essential to use some sort of a depressor with 
which to expose the cervix by holding the walls of the vagina 
apart. 

When the cervix is directed backward and is not readily exposed 

to view it may be hooked by a tenaculum and drawn forward. 

Such manipulations must only be carried out under the guidance 

of the eye or finger, for fear of hooking the vaginal wall instead of 

the cervix. 

(79) 



80 GENERAL DIAGNOSIS 

Simons' speculum is a device not unlike that of Sims', having a 
single spoon instead of two. It has an advantage over Sims' 
speculum in that there is no second handle to interfere with the 
manipulation of the instrument. 

A combination of spoons of various shapes and sizes adjusted to 
separate handles was devised by Bozeman and others. 

For the purpose of exposing the cervix the lateral walls of the 
vagina may require retraction. 

The bivalve speculum is in general use, though inferior in every 
respect to the Sims and Simons. Cusco's lateral modification is 
simple and easily manipulated. 

The instrument consists of two blades, taking the form of a 
beak. The articulated outer end is manipulated by a screw which 
spreads the valves to an acute angle. The instrument is closed 
and inserted by its smaller diameter, and when inserted the instru- 
ment is turned so that the screw points toward the perineum. As 
the blades are separated they tend to distend the vagina, and the 
cervix engages between the blades. The great objection to this 
instrument is that the anterior and posterior walls of the vagina 
are obscured by the blades, and the traction upon the vaginal 
walls separates the lips of the cervix to an unnatural degree. The 
one great advantage is the fact that it is a self-retaining speculum, 
requiring no assistant to hold it. 

In withdrawing the instrument care must be exercised for fear 
of catching folds of the mucous membrane; the instrument must 
be withdrawn slowly and the screw gradually loosened as the 
speculum is retracted. 

The tubular speculum is seldom used. It is made of metal, wood, 
celluloid, glass, or vulcanite, and may be introduced in the lith- 
otomy, knee-chest, or Sims position. It can only expose the cervix, 
and this is done with difficulty. 

The self-retaining speculum, composed of a spoon-like blade 
and a weighted handle, will be found of the greatest service in 
making an exploratory curettage and in excising pieces from the 
cervix. 

Currier s weighted self -retaining speculum with two adjustable 
blades is an admirable device. 

Too much emphasis cannot be placed upon the necessity of 
surgical cleanliness in the use of vaginal specula. 



THE VAGINAL SPECULUM 81 

Some operators who scrupulously sterilize all instruments intended 
to be introduced into the uterus carelessly use a speculum after little 
or no cleansing. Gonorrhoeal infection is frequently transmitted 
in this manner. 

To fail to sterilize the vaginal speculum before using is criminal 
negligence. 



CHAPTEK IX. 

THE VULSELLA. 

Traction upon the cervix is made with the vulsella forceps. 
When the uterus and its attachments are in a normal position the 
cervix can be drawn almost to the vulvar outlet. Little or no pain 
is caused by the grasp of the forceps upon the cervix. 

A vaginal speculum need not necessarily be used in grasping the 
cervix with the vulsella forceps; the finger may be used as a guide. 

As an aid to diagnosis the vulsella forceps are used to make 
traction upon the uterus, bringing it and adjoining structures 
within easier reach of the examining finger in the vagina or rectum. 

In determining the relation of large tumors and swellings to the 
uterus, it is of advantage to steady the uterus by making traction 
downward upon the cervix. The forceps are held by an assistant 
while the examiner manipulates the tumor. If tumor and uterus 
move together there must be an intimate connection between the 
two. 

In differentiating an erosion from an eversion of the cervix the 
two lips of the cervix are grasped by the vulsella forceps and 
the lacerated edges approximated. If the red surface disappears 
an eversion is diagnosed; if there still remains a red zone about 
the external os an erosion must be present. 

In removing sections from the cervix for diagnostic purposes the 
cervix is grasped by the vulsella forceps. 

Forcible traction upon the cervix is not without danger. It is 
possible to rupture the peritoneum and to tear through adhesions. 
Acute inflammatory lesions of the pelvis are absolute contraindi- 
cations to the use of the vulsella forceps lest the inflammation 
be excited to further extension. In the pregnant uterus severe 
hemorrhage may be brought on by the application of the forceps. 

In removing the vulsella forceps care is to be exercised for fear of 
injuring the cervix or wounding the patient. Superficial sutures 
of catgut or a vaginal pack with iodoform gauze may be placed if 

hemorrhage is severe. 

(82) 



PLATE X. 




Palpation of the Pedicle of an Ovarian Cyst. 

Two fingers are inserted into the rectum and the opposite hand over the abdomen. An 
assistant makes traction upon the cervix with a vulsella forceps while a third assistant 
grasps the cyst with both hands and draws it upward. In this manner the pedicle is put 
upon the stretch and can be engaged between the fingers in the rectum and those on the 
abdomen. 



CHAPTEE X. 

UTERINE DILATORS. 

For the purpose of exploring the uterine cavity with the finger 
and curette the cervix must be dilated. Hegar's or Kelley's dilators 
are recommended for general use. By them the cervix is sym- 
metrically dilated, with a minimum amount of trauma. 

The vaginal speculum should always be used to expose the 
cervix. The anterior lip of the cervix is grasped by a vulsellum 
forceps. The dilators are sterilized by boiling, and lubricated 
with sterilized glycerin or boroglycerin. Beginning with a size 
that can easily be passed through the cervical canal, one after 
another of the sounds is passed until the cervix will admit the 
index finger. 

The utmost care must be exercised in passing the dilators for fear 
of losing control of the instrument and accidentally forcing it 
through the uterine wall. To eliminate this danger the depth and 
direction of the uterus should first be ascertained by the sound. 
The dilators are then grasped by the thumb and index finger at a 
point about one inch short of the length of the uterus. 

Instruments of divulsion, such as Palmer's, Goodell's, and Ellin- 
ger's, are commonly used in America. Only moderate force should 
be applied in dilating with these instruments for fear of tearing the 
cervix. They do not find favor in Europe. 

Tents are seldom used of late. They are not only slow and 
uncertain in their action, but are a source of danger from infection. 
They are made of sea-tangle, sponge, and tupelo. A detailed 
account of the manner of their insertion and use is to be found in 
text-books on gynecology. 

Where great resistance is offered to the dilators, a unilateral or 

bilateral incision in the cervix may be made. Digital dilatation of 

the cervix is sometimes possible shortly after abortion or full-time 

labor. By first inserting the little finger, then the index, and 

lastly the middle finger, the cervical canal may at such times be 

safely and efficiently dilated. 

(83) 



CHAPTEE XI. 

THE UTERINE SOUND. 

Preliminary Procedures. 
Indications. 
Contraindications. 
Dangers. 

^Etius speaks of using the sound to measure the length of the 
vagina. Sir James Y. Simpson introduced the modern sound as 
a material aid in the diagnosis of lesions involving the uterus. 
Simpson does not deny that the sound was used for exploration and 
measurements of the uterus long before his time. Certain it is that 
Wierus used the sound for like purposes as early as 1637. Begin- 
ning with the indorsement of Simpson and up to the present time 
the sound has been used too freely and not without danger. Since 
the bimanual method of examination has been largely practised 
the use of the sound has been materially restricted. It is seldom 
necessary to pass the sound in the consultation-room. The bimanual 
examination will usually suffice. 

In the construction of a uterine sound there are certain require- 
ments. The instrument should be made of a flexible metal, prefer- 
ably of copper, and nickel plated; the distal end should be rounded 
and knob-like; the hands should be flat and grooved on one side 
only. Beginning two and one-half inches from the distal end the 
sound should be graduated every half-inch for the purpose of 
measuring the depth of the uterine cavity. 

Preliminary Procedures. Before the sound is passed certain 
precautionary measures are necessary. First, there must be sur- 
gical cleanliness in the preparation of the field of operation, the 
instruments, and the hands of the operator. Second, a bimanual 
examination should be made to determine, if possible, the position 
of the uterus. By adhering to these preliminary precautions the 
dangers of infection and perforation are minimized. The most 
convenient position is the lithotomy, though it is possible to intro- 
duce the sound with the patient in the lateral or knee-chest position. 
(84) 



THE UTERINE SOUND 



85 



Fig. 15 




^K 



Indications for the Use of the Sound in Diagnosis, l. The 
depth of the uterine cavity is accurately measured by the sound. Its 
average normal depth is two and a 
half inches in a nullipara of mature 
years, and this is increased about 
one-half inch in the multipara. 

(a) The depth of the uterine cavity 
is lessened in acquired and con- 
genital atrophy, atresia of the uterus, 
inversion of the fundus, and in new- 
formations encroaching upon the 
cavity of the uterus. 

(6) The depth of the uterine cavity 
is increased in pregnancy, subinvolu- 
tion, elongation of the cervix, endo- 
metritis, metritis, and new-growths 
of the uterus. 

2. The direction of the uterine canal 
is often changed from the normal 
by new-growths in and about the 
uterus, by senile involution, by 
inflammatory contraction, and by 
displacements of the uterus from 
whatever cause. As stated under 
preliminary precautions, it is always 
wise to precede the passage of the 
sound by a preliminary bimanual 
examination. If the relation of the 
body to the cervix is determined, 
the sound is curved at the proper 
angle before it is introduced. By so 
doing there is less danger of punc- 
turing the uterus. 

3. Stenosis and atresia of the uterine 
canal are definitely determined by 
the sound. Apparent stenosis at the point of flexion is often made 
to disappear by traction upon the cervix with vulsella forceps. 

4. Irregularities of the mucosa, if not too small and soft, may be 
detected by the sound. Such irregularities are submucous fibroids, 



Simpson's graduated sound. 



86 



GENERAL DIAGNOSIS 

Fig. 16 




First step. Thfei^dund is guided to the external os along the palmar surface of the index 
finger or the speculum is used. The patient is in the dorsal position. 






Fig. 17 




Second step. The sound is passed slowly into the uterine cavity. The direction taken by 
the sound is carefully noted. The patient is in the dorsal position. 



THE UTERINE SOUND g7 

polyps, malignant growths, and retained placental tissue. When 
possible to use the finger it is always preferred to the sound. 

5. The Thickness of the Uterine Wall. By passing the sound 
into the uterus and with one hand over the abdomen, the fingers of 
the other hand in the rectum, it is possible under favorable con- 
ditions to make a fair estimate of the thickness of the uterine wall. 

Contraindications to the Use of the Sound. 1. Menstruation. 
Though not an absolute contraindication, it is better to delay the 
procedure until the intermenstrual period. 

2. Pregnancy is an absolute contraindication for the passage of 
the sound. While the sound has been passed into a gravid uterus 
without interrupting pregnancy, it is never justifiable to pass the 
sound where there is a possibility of pregnancy. 

3. Malignant growths, while not an absolute contraindication, are 
to be regarded as a source of danger and demand very cautious use 
of the sound for fear of exciting hemorrhage. 

4. Acute pelvic inflammation is a contraindication for the use of 
the sound as well as for all manipulations of the pelvic viscera. 

DANGERS INVOLVED IN THE USE OF THE SOUND. 

1. Infection of the uterus may be caused either by an unclean 
instrument or by carrying the infection from the lower genital tract. 
Forcible and careless manipulations injure the delicate mucosa, 
thereby producing an atrium for infection. Because of the danger 
of infection the custom of passing the sound in the routine office 
practice is condemned. 

2. Perforation of the uterus is an accident that may happen to the 
most cautious operator. The uterine wall may be so soft as to 
offer no perceptible resistance to the passage of the sound into the 
peritoneal cavity. Such softening may be due to infection and to 
malignant infiltration. 

3. Hemorrhage may be alarming in the case of malignant growths 
of the uterus, in hydatid mole, and in incomplete abortion. 

4. Pelvic inflammation may be occasioned by the passage of a 
sound into the uterus. This is seldom the case in the absence of a 
pre-existing infection. 

It is dangerous practice to test the mobility of the uterus by 
means of the sound. The bimanual examination with or without 
anaesthesia should afford all needed information with far less risk. 



CHAPTER XII. 

THE UTERINE CURETTE. 
Indications. 
Contraindications. 
Dangers. 
TechniquEc 

The fact that the uterine curette is universally used speaks for 
its utility; but, as with many of the great and useful things of life, 
it is equally capable of harm in the hands of the incompetent. 

The use and abuse of the uterine curette is a subject that should 
engage the careful consideration of the general practitioner far more 
than many of the more pretentious problems in the treatment of 
diseases of women, because the curette is the most used and the 



Fig. 18 




Blake's curette. 



Fig. 19 



Boldt's double curette. 



most abused of the armamentarium of the gynecologist, and, I 
might add, of the general practitioner. 

Let us briefly consider the indications for the use of the uterine 
curette in the diagnosis of the diseases of women. 

The uterine curette in diagnosis may be used in any of the 
lesions within the uterine cavity and involving the endometrium. 

1. First in order of clinical importance and frequency is endo- 
metritis. An excessive menstrual flow and a so-called leucorrhoeal 
discharge from the uterus, together with a history of infection, 
generally suffice for a clinical diagnosis of endometritis; but a 
positive diagnosis — one that amounts to a scientific certainty — can 
only be made by a microscopic examination of scrapings removed 
(88) 



THE UTERINE CURETTE 89 

by the curette. All of the clinical signs of endometritis may be 
present without inflammatory changes in the endometrium, and, on 
the other hand, endometritis may be present to a marked degree 
in the absence of any clinical evidence. It is never justifiable to 
curette the uterus for the purpose of differentiating between the 
various anatomical forms of endometritis, but rather to determine 
the fact of endometritis and to exclude other possible lesions, such 
as retained placental tissue and carcinoma. It is a matter of little 
concern whether we have to deal with a hypertrophic or hyper- 
plastic, a fungus, or a polypoid endometritis. It is the fact of the 
presence of endometritis and not of the particular anatomical 
variety that is of practical clinical importance. 

2. Retained products of conception may remain attached to the 
uterus for years, giving rise to hemorrhage and leucorrhoea, the 
cause of which can only be demonstrated by exploring the uterine 
cavity. In all such cases the finger, if possible, should be used in 
locating and removing the retained fetal tissue. Shortly after 
abortion and labor curetting is rarely justifiable because of the 
dangers involved. 

3. The firm, rounded bulging of a submucous fibroid is sometimes 
demonstrated by means of the curette. 

4. Malignant growths of the endometrium can only be diagnosed 
in the early stage by microscopic examinations of scrapings. There 
may be no symptoms, or merely those common to endometritis, and 
this is even possible in cases far advanced. In my personal expe- 
rience the systematic examination of uterine scrapings has frequently 
brought to light an unsuspected malignant growth, and that which 
has passed clinically for malignancy has been demonstrated to be 
endometritis or retained placental tissue. 

Syncytioma malignum — i. e., a malignant degeneration of 
placental tissue — is a rare finding, but because of its rapid spread 
and fatal issue an early diagnosis is imperative. When an unac- 
countable hemorrhage from the uterus occurs weeks or months 
after labor or abortion, and particularly after the expulsion of a 
hydatid mole, an exploratory curettage is demanded, and a micro- 
scopic examination should be made in view of the possibility of 
finding malignant changes in the placental remains. 

There is no more important and certainly no more satisfactory 
procedure in all the range of diagnosis than the differential diag- 



90 GENERAL DIAGNOSIS 

nosis of uterine scrapings. A sharp line cannot always be drawn 
between the benign and the malignant, but in the hands of a com- 
petent observer such failures are unusual. 

In the diagnosis of ectopic pregnancy it is sometimes advisable to 
curette the uterus to determine the presence of decidual tissue. 
Great caution must be exercised for fear of rupturing the gestation 
sac. 

Contraindications to the use of the curette are first of all 
menstraation. This is not an absolute contraindication, but it is 
seldom that the procedure cannot wait until the menstrual period 
is passed. 

2. Pregnancy. The possibility of pregnancy must be positively 
excluded. Where doubt exists after a thorough examination it is 
always well to await developments for a month or more. A good 
rule to follow is never to use the curette in cases of delayed men- 
struation where pregnancy is at all possible. 

3. Acute and subacute pelvic inflammations are contraindications, 
because of the danger of extending the infection. It is always wise 
to wait until the pelvic inflammation has subsided before curetting. 
Distended tubes and ovaries are liable to rupture. No harm will 
likely result if the contained matter is serum, but if pus escapes 
the consequences may be disastrous. 

The dangers involved in curettage are by no means trivial. 
The curette is a formidable instrument, and curettage is not to be 
regarded as a minor operation and without danger. 

1. As with all operations, there is the risk of septic infection 
through the wounded surface. The liability to infection is not 
great when the uterus is firmly contracted; but in the puerperal 
uterus, with large venous sinuses and possible infection already 
existing therein, all the conditions are present favoring a wound 
infection. 

2. Hemorrhage is an unlooked-for complication, yet in puerperal 
and malignant cases the loss of blood may be alarming and fatal. 

3. The danger of exciting an acute exacerbation of a pre-existing 
pelvic inflammation is always imminent. 

4. Perforation of the uterus by the curette is an accident that may 
happen to the most skilled and cautious surgeon. I venture the 
assertion that not an operator of large experience has escaped this 
misfortune. We are not to be assured by the statements frequently 



PLATE XI. 



FIG. 1, 




Gradxxated. bougies are used for the dilatation of the cervix. This method 
is preferable to that shown in Fig. 2, 



FIG. 2. 




Cervix is exposed by a self- retaining speculum and grasped at its anterior 
lip by a vulsellum forceps. Traction is made upon the cervix as the cervix 
is dilated by an instrument of divulsion. Patient in dorsal position. 



PLATE XII. 



FIQ. 1. 




Curettage of the Uterus. 



FIG. 2. 




Curetted Surface is Swabbed >A^ith Pure Formalin. 



THE UTERINE CURETTE 91 

made that the perforation is of httle consequence. In a puerperal 
infected uterus the uterine wall may offer no more resistance to the 
curette than would blotting paper; the instrument passes through 
the wall apparently meeting no resistance. In such cases our only 
safeguard lies in discarding the curette, both the dull and the sharp. 
The fingers, placental forceps, and douche are all sufficient, save in 
very exceptional cases. Not only is the finger less likely to per- 
forate the uterus, but by the finger the placental site is located and 
the adherent placenta removed, leaving the remaining uterine 
surface intact, as it should be. Nature has thrown out a barrier 
in the decidua in the form of leukocytes or phagocytes, the so-called 
"protective zone," that will resist the invasion of micro-organisms 
if it is possible for anything to do so. The curette would but tear 
away this protective wall and allow a direct invasion of the venous 
sinuses by the septic organisms. 

5. The removal of the decidua down to the musculature is a possible 
danger when the curette is used. With the finger this accident will 
not occur. From the decidua the new endometrium is regenerated, 
and if completely scraped away there will be left in its place a 
permanent scar surface, rendering the woman sterile and a sufferer. 

The same result, though to a lesser degree, may follow too 
vigorous scraping of the non-puerperal uterus. The grating of the 
instrument is a sign that the mucosa is removed down to the deeper 
and firmer layer, and it is time to stop lest the entire mucosa be 
removed. 

The following is an outline of the technique of curettage : 

1. Anaesthesia, preferably chloroform. 

2. Sterilization of the vulva and vagina. 

3. Dilatation of the cervix with Hegar's bougies or an instrument 
of divulsion. 

4. Introduction of a curette to one of the uterine horns and deliber- 
ately sweeping downward as far as the internal os. Passing by 
successive sweeps along the posterior wall to the opposite horn, 
then to the side and in front to the original point of attack, making 
sure that no furrows or patches are left by again going over the 
surface in a similar manner. 

5. Irrigating the uterus with salt solution. As a routine practice 
I would recommend swabbing the uterus with full strength formalin. 

6. No uterine pack is recommended unless the uterus is relaxed 



92 GENERAL DIAGNOSIS 

and bleeding freely. A sterilized vaginal tampon may be inserted 
against the cervix for twenty-four hours, then removed, and 1 per 
cent, lysol douches or formalin (1: 1000) may be given daily for a 
week. 

7. Rest in bed should be enjoined for a period of four or more 
days. 

8. No escharotics should be used. The sharp curette should be 
used in all cases, with the exception of a puerperal uterus, when a 
dull curette is employed after more conservative methods have 
failed. (See Plates XI. and XII.) 



CHAPTEE XIII. 

MICEOSCOPIC EXAMINATION :0F SCRAPINGS AND 
EXCISED PIECES, 

The microscope is indispensable in the diagnosis of diseases of 
women. The microscopic examination of scrapings and excised 
pieces constitutes one of the most important and gratifying means 
of determining the character of lesions involving the cervix and 
endometrium. 

The bimanual examination will alone determine many of the 
affections of the pelvic viscera; inspection of the vagina and vaginal 
portion of the cervix through a speculum will afford much informa- 
tion; direct palpation of the cervical canal and cavity of the uterus 
will add much to our knowledge of the extent and character of the 
lesions involving these surfaces^ the clinical symptoms are important 
in the consideration j but a positive diagnosis, one that admits of 
no reasonable doubt, is often reserved until a microscopic exam- 
ination of scrapings and excised pieces has been made. 

Very often the microscope serves to verify a clinical diagnosis, 
but in not a few cases a previously unsuspected condition is brought 
to light by a microscopic examination of scrapings from the endo- 
metrium and excised pieces from the vaginal portion of the cervix. 

The author does not claim that the microscope is an infallible 
means of making a diagnosis. In exceptional cases the diagnosis 
remains in question after all means — the microscope included — 
have been exhausted. 

REMOVAL OF UTERINE TISSUE FOR DIAGNOSTIC PURPOSES. 

In all cases^ unless contraindicated^ a general anaesthetic is advis- 
able. Cocaine may be used as a local anaesthetic in excising pieces 
from the cervix. When the tissue is soft and friable, as in carci- 
noma, no local or general anaesthetic may be required. 

It is not necessary to shave the vulva, but by scrubbing and 

douching the field of operation is made clean. 

(93) 



94 GENERAL DIAGNOSIS 

The position assumed by the patient may be the Sims or lith- 
otomy. If the former, the Sims or Simons speculum is used; if 
the latter, the Simons or self -retaining speculum is preferred. The 
self-retaining speculum is especially advantageous because no 
assistant is needed. 

Test Excision from the Cervix. After grasping the anterior lip 
of the cervix by the vulsella forceps, a small wedge is cut from the 
cervix by angular scissors. In selecting a portion for excision an 
effort should be made to include in the removed piece a part of the 
healthy together with the diseased tissue for the purpose of studying 
the transition stages. 

Hemorrhage is to be controlled by a gauze pack, or, when neces- 
sary, by the placing of absorbable sutures. 

Test Curettage of the Uterus. The cervix is dilated sufficiently 
to admit a moderate-sized curette. The instrument is passed under 
control of the eye by the aid of a Sims or Simons speculum. The 
patient is in the Sims or lithotomy position. In order that no 
portion of the endometrium escape the curette, the uterus should 
be scraped systematically and thoroughly, beginning at one horn 
and sweeping deliberately down to the internal os, passing in this 
manner over the entire inner surface of the uterus, taking care that 
no portion of the endometrium be missed. Before the blood has time 
to firmly coagulate the scrapings should be removed to a 4 per cent, 
solution of formalin. Allowing them to lie long in water causes 
maceration. All particles in the scrapings are to be carefully pre- 
served, so that if necessary the entire specimen may be examined. 

Frozen Specimens of Excised Pieces and Scrapings. Where an 
immediate diagnosis is required the freezing method may be em- 
ployed with fairly satisfactory results. It occasionally happens 
that the examination of excised pieces and scrapings will determine 
the question of a more radical procedure. If by reason of expediency 
or added risk from a second anaesthetic it becomes necessary to 
proceed without delay, frozen sections may be prepared and diag- 
nosed while the patient is being prepared for a radical operation. 
Not more than twenty minutes are required for the examination. 

The following is the method employed in Johns Hopkins Hospital 
by Cullen: 

(a) Place the frozen section in 5 per cent, aqueous solution of 
formalin for from three to five minutes. 



MICROSCOPIC EXAMINATION OF SCRAPINGS 



95 



(b) Leave in 50 per cent, alcohol one minute. 

(c) In absolute alcohol one minute. 
{d) Wash out in water. 

{e) Stain in hsematoxylin two minutes. 
(/) Decolorize in acid alcohol. 
{g) Rinse in water. 
(Ji) Stain with eosin. 

Fig. 20 




Bardeen CO2 freezing microtome. This microtome is an improved pattern after designs by 
Professor C. R. Bardeen, of Johns Hopkins University, and is a most excellent instrument 
for regular pathological and other demonstrations. It is indispensable for clinical "work 
where stained sections of morbid tissues are required within a few minutes of the begin- 
ning of an operation in order that the surgeon may determine his mode of procedure. It 
freezes almost instantaneously regardless of room temperature or humidity and at very 
small expense. The temperature of the object to be frozen is, within limits, under the con- 
trol of the operator. The freezing chamber contains a spiral passage through which the 
expanding CO2 passes, securing the maximum freezing power. The knife slides on glass 
guides. The finest feed is twenty microns. The microtome may be attached directly to a 
COo cylinder. 



96 



GENERAL DIAGNOSIS 



(i) Transfer to 95 per cent, alcohol. 

(j) Pass through absolute alcohol, then through creosote or oil 
of cloves, and mount in Canada balsam. 

While the freezing method has an important place in connection 
with the operating-room, the sections are not eminently satisfactory, 
for the reason that only small sections can be made and differ- 



FiG. 21 




Ether or rhigolene freezing attachment. This attachment consists of a cylindrical freez- 
ing stage upon which the object to be frozen is placed and against which a very fine 
spray of ether or rhigolene as desired is projected by a delicate atomizer operated by the 
bulb air-pump shown in the illustration. The rapid evaporation of the fluid abstracts 
sufficient heat from the object to freeze it in a short time. There is always, however, an 
excess of fluid which does not evaporate, and this is drained back into a bottle and used 
again. This freezer is applicable to the automatic laboratory, medium laboratory, student, 
table, and demonstration microtomes. 

entiating stains cannot be used. Where an immediate diagnosis is 
not required (and this is true in the majority of instances) the 
celloidin or paraffin methods are preferred. 



FIXING THE SPECIMENS. 



Zenker^ s fluid (Miiller's fluid, 100 per cent.; bichloride, 5 per cent., 
and, shortly before using, the addition of 5 per cent, of glacial acetic 



MICROSCOPIC EXAMINATION OF SCRAPINGS 97 

acid) is an excellent fixing fluid, preserving the blood in its natural 
color. After fixing in Zenker's for twenty-four hours the section 
is placed in cold running water for twenty-four hours or in a weak 
iodine solution for a like time. The section is then ready for harden- 
ing in alcohol. No better fixing fluid can be used where time will 
permit. It is often well to place the entire uterus in Zenker's fluid 
for a week or more before cutting sections from it. 

Alcohol as a fixing agent is objectionable because of the shrinkage 
of the tissues. Where it is desired to examine for micro-organisms 
alcohol is of special value. 

Formalin may be used in a 2 to 4 per cent, solution. It is objected 
to because of the difficulty in cutting the musculature. 

HARDENING AND EMBEDDING. 

When it is desired to prepare the section hurriedly, a small piece 
is placed immediately in absolute alcohol and changed three or 
four times in twenty-four to thirty-six hours, when it is ready for 
embedding. 

When an additional day or two can be taken better sections are 
made by running the pieces through successive strengths of alcohol 
and changing every two to twelve hours through 70, 80, and 90 per 
cent, and absolute alcohol. 

It is now necessary to embed the section in a substance which 
will permeate the tissue, filling up all spaces and giving support to 
the section while being cut and mounted. 

The embedding of a specimen in celloidin follows upon the harden- 
ing process. For general purposes the celloidin method is pre- 
ferred. From absolute alcohol the section is placed in equal parts 
of sulphuric ether and absolute alcohol for from six to twenty-four 
hours, depending upon the size of the section. Next the section is 
changed to a dilute solution of celloidin in ether for from six to 
twenty-four hours; it is then placed in a thick solution of celloidin 
in ether for an equal time, when it is ready to mount upon a cork 
for sectioning. 

After blocking the specimen on wood or cork it is allowed to 
fix firmly in the open air or under a bell-jar, and is then placed in 
70 per cent, alcohol for an hour or more. The section is now ready 
for cutting and mounting, 

7 



98 



GENERAL DIAGNOSIS 



The embedding of specimens in paraffin is an excellent method 
for general laboratory purposes, but is somewhat complicated for 
private laboratory use. When the tissues are soft and small, as in 
scrapings, ideal sections are prepared by this method. For serial 
sections no other method can be employed. After thoroughly 
dehydrating the tissue the specimen is immersed in a solution of 



Fig. 22 




The student microtome. This is intended for individual and laboratory use where a 
reliable mechanical microtome at small cost is required. It is extremely simple, yet very 
accurate in construction. This is one of the few models which have I'emained practically 
unchanged, showing that it is adapted for its work. The stand is one solid piece of metal. 
The knife block is as heavy as is consistent with the size of the instrument. The feed 
arrangement is carried in a metal stirrup attached permanently to the front of the 
stand, and consists of an accurately cut micrometer screw having a pitch of 0.5 mm., with 
a graduated head divided to 100 parts, each graduation, therefore, having a value of 5 
microns. The object clamp is adjustable in two planes, and can be set for paraffin or 
celloidin cutting. 



zylol and paraffin, or in chloroform and paraffin, for from two to 
twenty-four hours, and is kept at a uniform temperature of 37° C. 
Next the specimen is immersed in melted paraffin for a like time 
and kept at a temperature of 48° to 50° C. It is then removed to a 
cool place and is quickly solidified in the paraffin, after which it is 
blocked out with a knife and mounted on a cork for cutting. 



MICROSCOPIC EXAMINATION OF SCRAPINGS 



99 



METHOD OF STAINING AND MOUNTING SECTIONS. 

Gelloidin Sections. For all practical purposes the hsematoxylin- 
eosin stain is most satisfactory. After cutting the sections and 
immersing them in water for a few moments, the following method 
is adopted: 

Fig. 23 




Lines of incision in opening the uterus after hysterectomy. 

1. Stain in hsematoxylin one to two minutes. 

2. Decolorize in acid alcohol. 

3. Immerse in weak ammonium- water until the blue color 
returns. 

4. Immerse in water to remove the ammonium. 

5. Counterstain in eosin from ten to thirty seconds. 

6. Immerse in 75 per cent, alcohol two minutes. 

7. Absolute alcohol one minute. - .. 

8. Clear in creosote or oil of cloves. 

9. Mount in Canada balsam. 

L.ofC, 



100 



GENERAL DIAGNOSIS 



Paraffin Sections. After cutting the sections they are carefully 
transferred to a shallow basin of warm water, on which they spread 
in thin ribbons. The water must not be hot enough to melt the 
paraffin, but merely sufficiently so to unfold the sections and spread 
them out smoothly. A glass slide is held underneath the sections, 
and they are made to float upon the slide. The slide is then with- 
drawn from the water, the water drained off, and is then placed for 
several hours on the top of an oven or radiator, where the moisture 



Fig. 24 




The uterine cavity exposed. 

is thoroughly driven from the slide and the section firmly fixed. 
The paraffin is dissolved in zylol or chloroform (by which the section 
is '^cleared"), and from this point on the staining is carried out in 
the usual manner. 

'*■ 

INSPECTION OF THE UTERUS AFTER REMOVAL. 

In order that a satisfactory examination rnay be made of the 
uterus after its removal, the operator should handle and mutilate the 
specimen as little as possible. Introduction of swabs, probes, and 



MICROSCOPIC EXAMINATION OF SCRAPINGS IQl 

curettes injure the endometrium and lead to false observations. 
Fig. 23 shows the method of opening the uterus. The body of the 
uterus is grasped by the left hand. Two incisions are made, as 
shown in Fig. 24, and the uterus is spread open in such a manner 
that the entire mucosa* will be exposed. Before the uterus is opened 
it is always well to fix it in Zenker's fluid for several days. The 
structures are thereby least disturbed in their relations. 

The color, consistency, outline, and measurements are all to 
be noted and recorded. Foreign growths and abnormalities are 
described in detail. 



CHAPTER XIV. 



EXPLOEATORY PUNCTURES AND INCISIONS. 

An exploratory puncture is not seldom resorted to for the purpose 
of completing the diagnosis. When conjoined examination fails to 
determine the nature of a pelvic tumor aspiration is an essential aid 
to the diagnosis. Collections of blood, pus, and serum in the tubes, 
ovaries, and pelvic tissues often cannot be diagnosed with certainty 
until the contents are procured either by aspiration or by incision. 
Furthermore, the character of the obtained fluid may not be recog- 
nized until submitted to a chemical, microscopic, and bacteriological 
examination. It is a growing conviction that an exploratory incision 
affords better results and is less dangerous than is aspiration. This 
is particularly true of abdominal explorations. 



Fig. 25 




Exploratory syringe. 



The instrument and field of operation must be rendered perfectly 
sterile. When surgical principles are carried out no harm should 
follow either procedure. Exploratory incisions are of value not 
only in determining the character of the contained fluids in the 
pelvis, but the procedure has a wide range of usefulness. Indeed, 
it may be truly said that every abdominal incision is in a sense 
exploratory. The abdominal surgeon very often encounters unsus- 
pected growths and adhesions, and, for this reason, one who is not 
master of any condition that may unexpectedly arise should not 

undertake to open the abdominal cavity. 
(102) 



CHAPTER XV. 

EXAMINATIONS OF THE BLOOD. - 

This chapter will be devoted to a discussion of the practical 
methods of making blood examinations and to their application in 
routine gynecological diagnosis. • In the Presbyterian Hospital of 
Chicago no gynecological case is operated before a blood examina- 
tion is made. In carrying out this routine the diagnosis has often 
been made more certain, the indications for operation have been 
more judiciously considered (not infrequently an operation has 
been postponed until the conditions of the blood were improved), 
the choice of the anaesthetic has hinged upon the blood findings, 
as has also the choice of operation, and finally, the prognosis has 
been influenced by repeated examinations of the blood. 

In routine clinical work the examinations of the blood are of no 
less importance than the analysis of the urine. In a large percentage 
of cases no additional information will be afforded by examining 
the blood, but in those cases where the responsibility is the greatest 
these examinations become of the highest value. Without a blood 
examination the writer would have submitted' one patient with 
17 per cent, of haemoglobin to an operation for hemorrhoids, and 
another patient with 20 per cent, of haemoglobin to an abdominal 
hysterectomy for uterine fibroids. In all probability the results 
would have been fatal from what is called surgical shock. Rest 
in bed and a liberal diet brought the former case up to 35 per 
cent, and the latter to 78 per cent, before the operations were 
undertaken. 

It is well known how misleading mere inspection may be even 
in making an approximate estimate of the degree of anaemia. A 
blood examination will 'often show a far greater degree of anaemia 
than was suspected. 

Only the methods of examination which are of practical applica- 
tion will be presented. Before entering" into a discussion of the 
subject the technique of estimating the number of blood cells and 
the percentage of haemoglobin will be briefly considered. 

( 103 ) 



104 



GENERAL DIAGNOSIS 



ESTIMATION OF THE NUMBER OF BLOOD CELLS. 

The Hsematocytometer. The instrument in general use is that 
of Thoma (Fig. 26). 

It is composed of a pipette and a counting chamber. The pipette 
is a graduated capillary tube surmounted by a bulb with a capacity 



Fig. 26 




The Thoma hsematocytometer. 



100 times that of the tube. A rubber tube is attached to the bulb, 
and to this is attached a mouth-piece. The capillary tube is grad- 
uated in ten equal divisions. Blood is drawn into the tube by 



Fig. 27 




Blood-countins- chambers of Thoma. 



suction up to the mark 1. Diluting fluid is then drawn into the 
tube until the mark 101 is reached. There are then 100 parts of 
fluid to 1 part of blood in the tube. The counting chamber is 
composed of a thick slide and a thinner glass plate. From the 



EXAMINATIONS OF THE BLOOD 105 

latter a central portion is cut out, and in this area is cemented a 
circular glass shelf with a surface y q- millimetre lower than the 
surface of the glass plate. A drop of diluted blood (1 per cent, 
dilution) placed on the shelf and covered with a glass cover-slip will 
be yq niillimetre thick. The shelf is ruled as shown in Fig. 27. 

There are nine square millimetres in the ruled area. The central 
squares are used for the red cells, the outer squares for the white 
cells. The central square is subdivided into 400 small squares, each 
square being ^^q- square millimetres. 

The diluting fluid is variously prepared. Ewing recommends 
that of Toisson or Hayem. 

Directions for Using the Haematocytometer. 1. The blood is 
obtained by puncturing the tip of the finger or lobe of the ear with 
a needle. By gentle pressure a drop of blood is expressed and drawn 
into the tube to the mark 1. The point of the pipette is wiped 
clean and inserted into the diluting fluid. The fluid is sucked 
into the tube to the mark 101, and the blood and fluid are well 
mixed by shaking. It is then ready for the count. 

2. The counting chamber is filled after making perfectly dry and 
clean. A drop of the diluted blood is placed upon the central shelf, 
and the cover-glass is so placed as to exclude all air-bubbles. The 
specimen is allowed to settle for a few moments, and the count of red 
corpuscles is then proceeded with. Before counting certain con- 
ditions must be present. The blood must not run underneath the 
cover-glass, the blood must be evenly distributed, no air-bubbles 
must be formed, and Newton's rings must be in evidence. 

3. The red cells are counted by a Bausch & Lomb \ objective, 
or its equivalent in the Zeiss, Leitz, or Reichert. Begin with the 
lower left-hand block of 25 squares, first counting all the red cells 
lying in the lower tier of squares from left to right. In each square 
all the cells which lie on the lower and left side lines are to be 
counted. Then proceed to count the cells lying in the tier above, 
including those which lie on the lower and right side lines of the 
tier below. This process is continued until at least four blocks of 
25 squares are counted and the number of cells counted is not less 
than 1000. 

4. The number of cells is computed by multiplying the number 
of cells found in 100 squares by 4000. This will give the number 
of red cells in a cubic millimetre. 



106 GENERAL DIAGNOSIS 

THE ESTIMATION OF LEUKOCYTES. 

It will be found most practical to count the white cells in the 
same preparation used for estimating the number of red cells. 
The Zappert-Ewing chamber is advised for this purpose. The 
number of white cells found in 6 to 18 millimetres depending upon 
the number of cells present will yield accurate results. A little 
methylene blue added to the diluting fluid will tint the white cells 
and make them more visible. 

The leukocyte count is coniputed by dividing the number of 
leukocytes by the number of square millimetres traversed, and 
multiplying this by 1000. This result is the number of leukocytes 
contained in a cubic millimetre of blood. 



THE ESTIMATION OF HEMOGLOBIN. 

Dare's hsemoglobinometer is a very practical instrument. It is 
easy to manipulate, accurate, and portable. It consists of a capil- 
lary blood chamber made up of two rectangular pieces of glass 
separated at one end by a thin space into which blood rises by 
capillary traction. This is compared with a color standard in a 
semicircular glass plate stained with Cassius' golden purple. The 
varying thickness of the plate gives colors which have been accu- 
rately adjusted to various percentages of haemoglobin. The color 
of the blood is compared with that of the standard scale. The 
light is provided by a candle attached to the case. For a detailed 
description of its use see special works on blood examinations. 

HISTOLOGICAL EXAMINATION OF BLOOD. 

Dry stained specimens are generally employed. The slides must 
be thoroughly cleansed and dried. A drop of blood is lightly 
expressed from the finger or lobe of the ear upon a slide. A thin 
film is made by a second slide as shown in Fig. 29. 

An effort should be made to evenly distribute the blood on the 
slide. The specimen is then dried in the air. It may be kept 
indefinitely without further preparation or may be fixed at once 
by passing over the flame of a Bunsen burner. Care must be taken 
to prevent overheating. 



EXAMINATIONS OF THE BLOOD 



107 



The staining of dry blood specimens may be best done by eosin 
and methylene blue or Ehrlich's triacid mixture. 



Fig. 28 





Dare's haemoglobinometer. X ^. Parts in position: R, milled wheel rotating colored 
disk and scale; S, case inclosing disk; T, shield which receives the camera tube U V 
(visible portion of disk backed by white glass) ; W, white glass back of capillary chamber • 
Y, candle holder. Contents of case: E, colored disk; F, clear glass disk graduated along 
edge H ; I, white glass back ; G, opening for pivot. 

(a) Eosin and Methylene Blue. Ehrlich's saturated alcoholic 
solution of blood-eosin and a watery 1 per cent, solution of Ehrlich's 
rectified methylene blue are the required stains. The methylene- 

FiG. 29 




Method of making blood smears. 



blue solution should not be less than one week old or more than 
eight weeks. The eosin solution also deteriorates in time. The 
method of staining is simple. Eosin is poured on the dry film for 



108 GENERAL DIAGNOSIS 

a few seconds and then washed oft* in pure water. The specimen 
is then immersed for one minute in methylene blue, hastily washed 
in water and dried. 

(b) Ehrlich's Triacid Stain. The method of application is very 
simple. The specimen is flooded with the mixture for one to two 
minutes and hastily washed in water. There is no danger of over- 
staining. It does not bring out the nuclei well, but stains the 
neutrophile and eosinophile granules deep red. It is, therefore, a 
perfect stain for the diagnosis of leukaemia. 

BACTERIOLOGICAL EXAMINATIONS OF THE BLOOD. 

Any sterile operating needle may be used. Fig. 30 represents 
an instrument modified by Ewing which is recommended for its 

Fig. 30 




Blood aspirator. (Half size.) 

simplicity. A small glass cylinder with ground tips is the receptacle 
for the blood. On the one end is a hypodermic needle, on the other 
a rubber tubing with a mouth-piece. There is a sterile glass tube 
to contain the apparatus. 

Blood is drawn from the median basilic vein after most careful 
sterilization of the field of operation. The culture mediutn is 
selected in accordance with the sort of organism sought for. 

MORPHOLOGY OF THE BLOOD CELLS. 

I. Red Cells. These cells are biconcave, disk-shaped bodies of 
a yellowish color in the fresh state. 



EXAMINATIONS OF THE BLOOD 109 

(a) Size. The diameter of the red cells in adults averages -g-^oiy 
inch and is almost constant within normal limits. In the marked 
anremias the diameter is more or less altered. There is little or 
no alteration in the mild forms of ansemia. 

1. MiCROCYTES are not found in normal blood. In severe types 
of ansemia small red cells known as microcytes are found in varying 
numbers. This is especially true of pernicious ansemia. 

2. Megalocytes are large red cells. They may be two and one- 
half times the average size of red cells. They indicate a chronic 
ansemia of severe grade. 

(6) Shape. Normal red cells are biconcave disks, but under 
certain impoverished conditions of the blood the margins present 
a serrated appearance (poikilocytes). 

(c) Average Number. The average number of red cells is 
4,500,000 to 5,000,000 to the cubic millimetre. This number shows 
great variation in the various forms of blood diseases. 

Nucleated Red Cells. Nucleated red cells are never found in 
adults under normal conditions. 

1 . Normoblasts do not differ in size from normal red cells, but 
contain a nucleus which occupies about one-third of the cell. They 
stain deeply and do not form rouleaux. In the absence of megalo- 
blasts they usually indicate a mild type of primary or secondary 
ansemia. 

2. Megaloblasts are larger than the normal red cells and con- 
tain a large nucleus. Taken alone they certainly suggest a morbid 
state of the blood, but their exact significance is implied by their 
associated red cells. They are of greatest significance in perni- 
cious ansemia, where they are found in large numbers, though the 
diagnosis may be made from the finding of a single megaloblast. 

Amount of Haemoglobin. It is of the utmost importance to 
estimate the relative amount of hsemoglobin. The various ansemias 
show great variations in this respect. 

II. White Cells (Leukocytes). Morphology. Leukocytes are 
colorless bodies varying in size and contained nuclei. As a rule, 
they are larger than red cells. They possess amoeboid movements. 

Five varieties are recognized: 

1. Lymphocytes both small and large. They have a round 
nucleus surrounded by a narrow rim of homogeneous or reticu- 
lated protoplasm. 



110 GENERAL DIAGNOSIS 

2. Large Mononuclear Leukocytes. They possess a coarsely 
reticular, vesicular nucleus surrounded by finely reticular proto- 
plasm. The nuclei may be round, horseshoe-shape, or elongated. 
The cell body is usually much larger than a lymphocyte. 

3. Polynuclear leukocytes are larger than mononuclear 
leukocytes. Neutrophile granules are found in the reticular 
protoplasm. The nuclei are elongated and may be connected 
by threads of chromatin. 

4. EosiNOPHiLE Leukocytes. Large granules are found in the 
protoplasm and take a deep eosin stain. The nuclei are usually 
bilobed. In size the cell is seldom so large as a polynuclear leuko- 
cyte. 

5. Mast-cells contain large and small basophile granules. They 
vary in size and in number of nuclei. 

Number of Leukocytes. The number of leukocytes in a cubic 
millimetre may be said to vary from 7000 to 10,000 within physio- 
logical limits. The number of leukocytes is notably increased in 
the newborn, during pregnancy, after ingestion of food, and after 
active exercise. 

Leukocytosis. An increase in the number of leukocytes above 
that of the normal for the particular individual under definite con- 
ditions is known as leukocytosis. For one individual 3000 leuko- 
cytes per cubic millimetre may be normal, while for another of 
greater vigor 10,000 may not exceed the normal limits. Again, a 
blood count taken shortly after a full meal or during pregnancy 
would naturally show an excess of leukocytes as compared with 
other physiological conditions. For purposes of comparison from 
time to time, the leukocyte count should be taken three or four 
hours after eating. 

In leukocytosis it is not only essential to know the number of 
leukocytes, but where the number is greatly in excess of the normal 
(25,000 to 80,000 to the cubic millimetre) it is also essential to make 
a differential count in order to distinguish a true splenic, myelog- 
enous, or lymphatic leukaemia from a leukocytosis incident to sup- 
puration, pneumonia, malignancy, and other morbid conditions. 
In the practice of gynecology and obstetrics it is seldom necessary 
to resort to a differential count. It may be stated as a safe rule 
to follow that where the white cell count exceeds 25,000 to the 
cubic millimetre a differential count should be made. And this 



^' / 



'=^' ATE XIII. 








/^ 



■^ ' 


















•«t&;< 




d 


»» ' '.ti'^fic 




.°>^=^ 






f 



LS. 



Iv sfranular (eos: 



T'Tn (=> Tv 1 ^ r>n f^i >i t i c\\ ?\i f ^ r rn pi 1 BloOCl 
leukocvtes ; f. small, and /, larg 



(^ 






m 



"^ 



Poikilocvtosis. 



§» (5^ 



^ 



nicious anajnii;i. 



EXAMINATIONS OF THE BLOOD HI 

rule becomes imperative where the local findings do not suggest 
suppuration, pneumonia, or malignancy, and where the general 
anaemia or enlarged spleen justifies the suspicion of a primary 
ansemia. It therefore becomes possible to say not only that the 
individual is sick, but it is possible to estimate to a certain extent 
the degree of illness, and thereby to formulate a more definite 
prognosis. 

Leukocytosis of Pregnancy. In the early weeks of pregnancy 
there is little increase in the number of leukocytes, but in the latter 
half the number averages about 10,000 to the cubic millimetre in 
primiparse. It is observed that leukocytosis is not so constant in 
multiparse — probably not more than 50 per cent, show an average of 
10,000. Near the time of labor the physiological limit may exceed 
18,000. Cabot found in three normal pregnancies a leukocyte 
count of 25,000 to 37,000. Since no leukocytosis is expected before 
the end of the third month a blood examination will aid little in 
the diagnosis of pregnancy. In the later months of pregnancy, 
when the question is raised as to the differential diagnosis of preg- 
nancy from other pelvic and abdominal swellings, leukocytosis will 
give little clue because in all such conditions it is expected that the 
leukocyte count will be high. 

Postpaxtum Leukocytosis. Following childbirth, where con- 
ditions are perfectly normal, the number of white cells gradually 
diminishes and usually returns to that of the non-pregnant state in 
about two weeks. Where much blood has been lost, or where there 
have been excessive lacerations or infection in the pelvis or breast, 
the usual diminution in white cells is interrupted. After-pains are 
said to interrupt the gradual diminution. 

Pathological Leukocytosis. Posthemorrhagic Leukocytosis. 
By experimental and clinical observations it is known that im- 
mediately following upon a severe acute hemorrhage there is an 
initial diminution in the number of leukocytes. Very soon a rapid 
increase in the number of white cells takes place. Within a few 
hours this leukocytosis may reach 45,000, and has been known to 
reach as high as 62,000. In three or four days it gradually recedes, 
but seldom returns to the normal in less than a month. The leuko- 
cytosis is usually proportionate to the amount of blood lost and to 
the acuteness of the attack. No such condition is observed in 
chronic hemorrhages. I have failed to observe leukocytosis in 



112 GENERAL DIAGNOSIS 

large but long-standing collections of blood in the pelvis from 
ruptured tubal pregnancy. 

The increase in the number of leukocytes immediately following 
upon postpartum hemorrhage is great in proportion to the* amount 
of blood lost. This is due to the contributing influence of pregnancy, 
which in itself causes leukocytosis to a variable degree. The 
leukocytosis disappears long before the number of red cells returns 
to the normal. It is difficult to explain the absence of leukocytosis 
in occasional cases of acute hemorrhages. 

Inflammatory Leukocytosis. It is a rule, to which there are few 
exceptions, that the number of white cells is increased above the 
physiological limit in septic infections, whether localized or general. 
This leukocytosis is proportionate to the virulence of the infection 
and to the resistance of the individual — not to the amount of 
exudate. A large pelvic abscess of long standing, containing no 
virulent micro-organisms and well walled off by firm adhesions, 
very frequently causes no leukocytosis. The greater the resistance 
of the individual the greater will be the leukocytosis. That is to 
say, an individual Avith poor resistance and a virulent infection 
may have no greater leukocytosis than an individual with high 
tissue resistance and a less virulent infection. It is observed that 
so long as the shock of an operation lasts leukocytosis does not 
appear, but just in proportion to the reaction of the patient from 
shock there is a development of leukocytosis, showing that without 
reaction of the tissues leukocytosis will not occur. A purulent 
exudate usually produces a higher degree of leukocytosis than does 
a serous exudate for the reason that the infection is more virulent. 
While it is possible for a fever to exist without an increase in the 
number of white cells, it is true that w^here the fever is solely 
dependent upon the infection, the leukocytosis will rise and fall 
with the temperature. Where the individual becomes overwhelmed 
with sepsis the tissues fail to react, and hence leukocytosis fails to 
appear, and the number of white cells increases in proportion to the 
reaction of the patient from the septic influences, and therefore 
may be regarded as a favorable omen rather than as evidence of 
increased infection. 

In a large number of observations on cases in which pus was 
confined to the tube, ovary, appendix, broad ligament, or cul-de-sac, 
the leukocytosis usually ranged between 12,000 and 19,000, the 



PLATE XIV. 



Fia. 1. 




Lymphatic Leukaemia. 

Large i\Iononuclear Lymphocyte. 2. Polymorphonuclear Leukocyte or 

Neutrophile. 3. Small Lymphocyte, dividing Nuclei 



FIO. 2, 




Splenornyelogenous Leuksemia. 

Myelocyte.- 2. Eosinophile I\Iyelocyte. 3. Normoblastic Red Corpuscles: dividing or 
fragmenting Nuclei. 4. Eosinophile Leukocyte. 5. Large Mononuclear Lympho- 
cyte. 6. Small Lymphocyte. 7. Polymorphonuclear Leukocyte or 
Neutrophile. 8. ]\Iegaloblast. 



EXAMINATIONS OF THE BLOOD 113 

maximum being 24,000. In long-standing pus tubes in which the 
contents were sterile the number of leukocytes did not exceed the 
normal. It is therefore seen that leukocytosis is not a constant 
factor in the presence of pus, but is directly proportionate to the 
virulence of the infection. The white count is therefore of no 
little value in determining the virulence of infection. In the 
presence of pus localized in the pelvis the determination of an 
accompanying leukocytosis will lead to early interference and will 
at least suggest the advisability of establishing drainage through 
the vagina rather than an abdominal incision. 

Leukoc3rtosis of Malignancy. In general it is said that the blood 
changes are proportionate to the degree of malignancy. The more 
rapid the growth and the greater the metastasis the more advanced 
the leukocytosis. No doubt in cancer of the uterus, vagina, and 
vulva the associated hemorrhages, if acute and great, contribute 
to the leukocytosis. The resisting power of the individual also 
influences the degree of leukocytosis. The effects upon the blood 
of sarcoma are of the same sort, but are said to be of a greater 
degree than in carcinoma. In thirteen cases of malignancy there 
was no leukocytosis in eight. Blood examinations will, therefore, 
aid little or not at all in the diagnosis of malignancy. The highest 
white count was 16,000. 

I have not observed that leukocytosis is more marked in sarcoma. 
In fact in the two cases observed the white count did not exceed 
10,000. 

Ansemia. It is of the greatest importance for the obstetrician 
and gynecologist to accurately diagnose both primary and secondary 
anaemias. Primary and secondary anaemias are not infrequently 
causes of amenorrhoea, menorrhagia, sterility, and abortion, and 
hence the recognition of the extent and variety of ansemia has a 
very special diagnostic value. Too often the physician assumes 
that the disorder is a local one when in reality it is a general blood 
affection. It becomes imperative to know the degree of ansemia 
before resorting to a major operation. The individual's general 
appearance is not a safe guide. The cases above referred to, one 
with 20 per cent, of haemoglobin and the other with 17 per cent., 
did not appear to be nearly so anaemic, and without a blood exami- 
nation would have been operated without knowledge of the great 
danger. 



114 GENERAL DIAGNOSIS 

Where the history points to a primary anaemia a differential blood 
count must be made. By cover-slip preparations and properly 
selected stains, chlorosis, pernicious ansemia, and the leukaemias 
are recognized. (See Plate XIII.) This together with the esti- 
mate of the number of red and white cells and the percentage of 
haemoglobin constitutes an exact diagnosis. 

Secondary anaemia is the result of some definite cause, as digestive 
disturbances, infection, and hemorrhage. In the mildest forms it 
is manifest merely by diminution in the size of the red cells and 
a corresponding decrease in the amount of haemoglobin. The 
number of red cells may not be lessened. Again, the red cells 
may assume irregular shapes and sizes (poikilocytes, microcytes, 
macrocytes). 

A still greater degree of anaemia is manifest by a decrease in the 
number of red cells as well as an alteration in their shape and size. 
As an indication of the most advanced type of secondary anaemia 
there are added to the alterations in the shape and size of the red 
cells and to the decrease in their number certain regenerative 
changes in the red cells. Nucleated red cells are found — normo- 
blasts, microblasts, megaloblasts. (See Plate XIV.) While writing 
this chapter I have under observation a seventeen-year-old girl 
who has but 10 per cent, of haemoglobin and 1,200,000 red cells 
as the result of uterine hemorrhages caused by a fibroid tumor. 
In high degrees of anaemia, where operative interference is indicated 
for relief from a pelvic disorder, the exact degree of anaemia is 
determined before resorting to the operation. It will be of interest 
to inquire as to the degree of anaemia which would contraindicate 
an operation. 

Each case must be a law unto itself. There are many things 
to consider : the urgency of the indication for operative interference, 
which may be very great in septic conditions and hemorrhage; 
the general condition of the patient other than that of anaemia; 
and finally the nature of the operation, particularly as to the 
duration of the anaesthesia required. I have curetted and packed 
the uterus under chloroform anaesthesia, where there was only 
20 per cent, of haemoglobin, for the purpose of controlling the 
hemorrhage until the blood could be built up to a point that would 
justify an abdominal hysterectomy for the removal of a uterine 
fibroid. Where pus can be drained through the vagina or the 



PLATE XV. 



FIG. 1. 



' O o j9q 

O O mO ^ 
O O • m 

o ^o o ^ 
^ o o o 

, i\ .. Co ^ 

, Q ^ ^ c) o 
o o o J>^ o 




o 



o O 



o 



o 



Cc 



Chlorosis. 



FIG. 2. 




Pernicious Ansemia. 

1. Large Mononuclear Lymphocyte. S- Small Lymphocyte. 

2. Polymorphonuclear Leukocyte or Neutrophile. 6 Poikilocyte. 

3. Megaloblast 1 ,, , , ^ , ^ , 7- Normal Red Corpuscle. 

4. Microblast f ^^^leated Red Corpuscles. 



PLATE XVI, 



j^w-^fe^i 



^*^, 




i^^f%.. 



M^ 




'/•»'.• 



• 



..^•. '•'.».:• 








f 






ii 




ii? 




A 

■^a^/ 






L.S. 



a, a group of red cells undergoing graLnular degeneration; h, red cells showing 
Cabot's ring bodies; c, normoblasts with nuclei undergoing karyolysis, the bodies of 
the cells show granular degeneration; d, normoblast with pyknotic nucleus; /, red 
cell, suggesting loss of nucleus by extrusion ; g, red cell undergoing mitosis ; k, 
megaloblasts with polychromasia of protoplasm; i, gigantoblast ; k, nucleated red 
cells with wheel-shaped nuclei undergoing cytolysis; /, a group of plaques. 



EXAMINATIONS OF THE BLOOD 115 

uterus curetted for the relief of sepsis and hemorrhage it would 
be wise to dispense with anaesthesia when possible if the blood is 
very low. 

In general it may be said that a protracted operation should 
not be done with the haemoglobin below 60 per cent., and the red 
cell count less than 2,000,000. There are exceptions to this rule, 
but all such cases must necessarily be hazardous. 



CHAPTER XVI. 

BACTERIOLOGICAL EXAMINATIONS. 
BACTERIOLOGICAL DIAGNOSIS IN DISEASES OF WOMEN. 

While the range of bacteriology in diseases of women is com- 
paratively circumscribed, the value of bacteriological examinations 
in selected cases cannot be overestimated. We are thereby enabled 
to arrive at the diagnosis of the essential cause of the infection. 
We determine whether the pus is sterile or virulent, and, having 
done so, the prognosis is made with more certainty and the method 
of procedure in treatment is more intelligently decided upon. 

The pathogenic organisms commonly found in the genital tract 
are the staphylococcus pyogenes albus and aureus, streptococcus 
pyogenes, gonococcus, colon bacillus, bacillus lanceolatus, and 
typhoid bacillus. There is great confusion in the literature regard- 
ing the relative frequency with which these organisms are found. 
Indeed, it is not possible to make any definite statement. 

The reader is referred to special works on bacteriology for detailed 
descriptions of the micro-organisms common to the genital tract. 
The author will attempt only a clinical consideration of the subject 
from a diagnostic point of view. 

Bacteriology of the Normal Genital Tract. The upper genital 
tract — i. e., cervix, uterine body, tubes, and ovaries are free from 
all forms of micro-organisms under normal conditions. Much 
difference of opinion exists as to the bacteriology of the vagina in 
health. That numerous bacteria are found in the healthy vagina is 
generally recognized, but to what extent if any these micro-organisms 
are pathogenic is an unsettled question. Numerous observations 
have been made to determine this question. Kronig, Menge, and 
Whitridge Williams carefully excluded the possibility of contamina- 
tion and agreed from extended observations that pathogenic organ- 
isms could not long exist in the healthy vagina. Their experiments 
were largely carried out during pregnancy. These authors ascribe 
to the vaginal secretion an antiseptic action which is more pro- 
(116) 



I 



BACTERIOLOGICAL EXAMINATIONS 117 

nounced during pregnancy. The vulva is rich in pathogenic as 
well as non-pathogenic micro-organisms. This accounts for the 
readiness with which the vagina is contaminated. It is of interest 
to know that the intact vaginal and vulvar surface will not admit 
of infection. In order that infection of these surfaces be possible 
there must be an atrium for infection acquired by direct injury, 
maceration of the epithelium from profuse irritating secretions, the 
development of malignant growths, or, lastly, the devitalization and 
desquamation cf the epithelium incident to old age. Not so with 
the delicate surface epithelium of the uterus and tubes. Here the 
infection is readily engrafted upon the healthy surface. Not infre- 
quently an infection acquired per vaginam will primarily attack 
the endometrium and later attack the vaginal surface when the 
epithelial covering has been macerated by the uterine secretion. 

Vulva and Vagina. Undoubtedly all sorts of pathogenic and 
non-pathogenic micro-organisms exist from time to time in the 
vulva and vagina. That they do not more frequently cause infection 
is due to the fact that the vulva and vagina are so well protected 
by stratified squamous epithelium. In infancy and old age when 
the epithelium has not the resisting power of mature life the vulva 
and vagina are more susceptible to infections and especially to gon- 
orrhoea. In the newborn the vagina is free from micro-organisms, 
but a variety of germs may enter soon after birth. It is agreed upon 
by all observers that pathogenic bacteria loose their influence as 
they approach the cervix. This fact is due, in all probability, to the 
presence of lactic acid, which in turn is the product of an acid- 
forming micro-organism discovered by Doderlein. This organism 
offers a restraining and often a prohibitive influence upon patho- 
genic organisms, thereby preventing the infection of the upper 
genital tract unless the organisms are carried there by hands and 
instruments. Certain organisms, particularly the gonococcus and 
streptococcus, may travel to the uterus in spite of the bacillus of 
Doderlein. 

J. Whitridge Williams made a study of the bacteria in the vagina 
of ninety-two pregnant women and came to the following con- 
clusions : 

1. We agree with Kronig that the vaginal secretion of pregnant 
women does not contain the usual pyogenic cocci, having found 
the staphylococcus epidermidis albus only twice in ninety-two cases^ 



118 GENERAL DIAGNOSIS 

but never the streptococcus pyogenes or the streptococcus aureus 
or albus. 

2. The discrepancy in the results of the various investigators is 
due to the technique by which the secretion is obtained. 

3. As the vagina does not contain pyogenic cocci, infection from 
them is impossible, and when they are found in the puerperal uterus, 
they have been introduced from without. 

4. The gonococcus is occasionally found in the vaginal secretion, 
and during the puerperium may extend from the cervix into the 
uterus and tubes. 

5. It is possible, but not yet demonstrated, that in very rare 
instances the vagina may contain bacteria, which may give rise 
to saprsemia and putrefactive endometritis by autoinfection. 

6. Death from puerperal infection is always due to infection from 
without, and is usually the result of neglect of aseptic precautions 
on the part of the physician and nurse. 

All infections of the vulva and vagina are mixed infections. The 
gonococcus, tubercle bacillus, diphtheria bacillus, staphylococcus, 
and streptococcus never exist alone, though they may so dominate 
in numbers and clinical phenomena as to be regarded as an isolated 
infection. 

Gonococcus infection of the vulva and vagina is rarely primary 
during the period of sexual maturity, but in infancy and in old age 
when the epithelium offers less resistance, primary vulvovaginitis 
is relatively frequent. The gonococcus is often found in the secre- 
tions of the vagina and vulva and occasionally when the secretion 
is not purulent. The Bartholinean gland, or rather the outlet of 
the gland, is the most frequent point of attack in the vulva. It is 
said that the gonococcus never invades the deeper ramifications of 
the gland. Here as elsewhere the infection is mixed. 

Tubercle bacillus infection of the vulva and vagina is rarely primary. 
As a rule, the infection is secondary to the uterus ; more rarely from 
the vulva, bladder, or rectum. Direct infection is possible, as is also, 
infection through the blood. 

Diphtheria bacillus infection of the vulva and vagina is commonly 
a puerperal infection conveyed directly to an injured tissue. I have 
seen but one such case. This one responded promptly to anti- 
toxin of diphtheria. The nurse acquired a diphtheritic sore 
throat. 



PLATE XVIL 



w 



e 



1^ / 



.»\: 












..M- 



% ^ ( 






^ f 



u 



fel" 



.4** 
















#,....• 






Ml 






• "•> 



• • V- 









7> ."^ 






'A 1?^ 



.3^ 



/V 









^^ 



a> 






9 



M^*^ 
K 



* "<*<»J^ '^Fm" 9 ft « 



T. Gonococcus of Neisser. 

2. Staphylococcus Pyogenes Albus. 

3. Pneumococcus of Fraenkel. 



4. Streptococcus Pyogenes. 

5. Tubercle Bacillus. 

6. Colon Bacillus. 



BACTERIOLOGICAL EXAMINATIONS 119 

Aerogenous infection of the vulva and vagina is manifested by the 
formation of small subepithelial cysts containing gas (emphysem- 
atous vaginitis). The infection is usually associated with preg- 
nancy. 

Uterus. Under normal conditions the uterus is at all times free 
from micro-organisms both pathogenic and non-pathogenic. The 
normal cervical secretion is said to possess a germicidal power. 
Even in chronic inflammation of the uterus bacteria are rarely 
demonstrated. Uterine infections are identical to those of the 
tube and are classified either as mixed or specific. It is highly 
probable that all uterine infections are mixed. The so-called 
specific infections are those in which a certain pathogenic micro- 
organism (streptococcus, gonococcus, tubercle bacillus) predomi- 
nates. The causes of imrnunity from infection of the cervix 
according to Sinclair are: 

1. Alkaline reaction of the cervical secretion. 

2. Small calibre of the cervix. 

3. Increased muscular power in the walls of the cervix. 

4. The downward stream of the cervical secretion. 

5. Germicidal quality of the cervical secretion. 

6. Presence of the gonococcus in the cervix. 

Fallopian Tubes. Under normal conditions no micro-organisms 
exist in the tubes. Few bacteriological examinations have been 
made from catarrhal salpingitis, and the results are not definite. 

In the purulent forms of salpingitis a large number of observers 
have made careful observations. Frank T. Andrews in writing of 
the causes of salpingitis {American Journal of Obstetrics, February, 
1904) has presented a valuable series of statistics collected from 
twenty-eight sources. The following table was constructed by 
Andrews : 



120 



GENERAL DIAGNOSIS 







6 


D 






a 




25 

m 
03 .1^ 


d 

a 

a 


CO 

'S 

a 

a 




"3 

03 

M 


CO 
13 

1 

s 

*o 


93 

a s 
.w a 

Is 


o 

CO 

3 . 


CO 

1 "^ 

g 
S3 


■3 


[ 
1 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 


Charrier, 
Hartman 

and Morax, 
Kelly, 
Koch, 
Legrog, 
Martin, 
Menge, 
Orthmann, 
Prochownik, 
Reichel, 
Schaflfer, 
Schauta, 
Schenk, 
Schmitt, 
Stemann, 
Strassmann, 
Wertheim, 
Westermark, 
Whiteside, 
Witte, 
Zweifel, 
Rist, 

Mackenrodt, 
Durck, 
Beilei, 
Walsh, G. 
Frommel, 
Andrews, F.T. 


6 
13 

28 

"i 

63 

68 

7 

5 

10 
69 

5 

"9 

15 

32 

3 

"5 
9 

26 


9 
13 

8 

21 

22 

1 

1 
1 

23 

1 

1 

16 

1 

17 

7 
8 
2 

"i 

la 
"5 


"i 
1 

"7 
5 

21 
15 

"i 

■3 

4 
3 

la 

1 

1 

12a 
5a 

"2 


"2 
"5 

"i 

4a 

1 

"i 


'l 
2 

i 
i 

ia 

i 

4a 
'7a 


ia 


... 

"ia 


1 


1 
la 

li 
2 

i 

"i 

1 

"6 
9 

"i 

3a 
4 

'4a 


15 
33 

38 

1 

1 

109 

97 

8 

27 

1 

11 

108 

1 

1 

1 

1 

23 

1 

27 

39 

44 

7 

1 

1 

20 

25 

1 

42 


a = mixed. 

a = 1 case mixed, 
a = mixed. 

a=2 cases mixed. 
a=7 cases mixed. 

a=2 cases mixed. 




Total, 


374 


155 


86 


14 


18 


1 


1 


1 


45 


684 





Sterile 55.0 per cent. 

Only saprophytes 6.0 " 

Gonococcus 22.5 " 

Staphylococcus and streptococcus . . . .12.0 " 

Pneumococcus 2.0 " 

Bacilli coll communis 2.5 " 



1. Gonococcus. The gonococcus of Neisser was found 155 times 
in 308 cases in which micro-organisms were demonstrated. Doubt- 
less a large proportion of the sterile tubes was originally infected 
with the gonococcus. The gonococcus frequently escapes detection 
because it early disappears from the pus contents of the tubes, and 
it is extremely difficult to recognize the gonococcus in the wall of 
the tube, though they have been known to exist many years. Mixed 
infections are the exception. In 36 cases of gonorrhoeal salpingitis 
other bacteria were found in 5. 

2. Streptococcus and Staphylococcus. These two micro-organisms 
are considered together, first, because they so commonly co-exist, 



BACTERIOLOGICAL EXAMINATIONS 121 

and, second, because their anatomical effects are much the same. 
Their virulence in the tube is variable. 

3. Pneumococcus of Frankel. The pneumococcus infections of 
the tube which have been reported bear no relation to pneumonia. 
The infection of the tube is probably acquired in these cases by 
direct extension from below. 

4. Bacillus Coli Communis. This infection is very often mixed, 
the colon infection being usually secondary to other forms. In the 
majority of cases the presence of the colon bacillus implies adhesions 
binding the tube to the bowel, though, as stated by Andrews, the 
infection may extend through the bowel wall, along the peritoneum 
to a non-adherent tube, or may travel up through the genital tract. 

5. Typhoid Bacillus. No direct connection has been traced 
between typhoid infection of the tube and typhoid fever, though it 
is possible that the typhoid bacillus may exist in tissues years after 
an attack of typhoid fever. 

6. Saprophytic Bacteria. Non-pathogenic bacteria of the sapro- 
phytic order are not infrequently found in salpingitis. 

7. Infectious Granulomata. Of the infectious granulomata tuber- 
culosis ranks first in frequency and in clinical importance. 

(a) Tuberculosis. In a total of 100 cases of pyosalpinx 
collected by Andrews, 10 per cent, were tuberculous. The tubes 
are usually the primary seat of genital tuberculosis — 57 out of 67 
cases (Meyer). On the other hand, Orthmann states that primary 
tubal tuberculosis occurs in 18 per cent, of genital tuberculosis in 
women; this in a series of 168 cases. Secondary tubal tuberculosis 
is relatively common, and is most often acquired through the blood. 

(b) Syphilis is rarely identified in the tube. Undoubtedly 
syphilitic lesions of the tube are common to general syphilitic infec- 
tion, but it is difficult to identify them as such. But three cases 
are recorded. 

(c) Actinomycosis of the tube is a great rarity. 

Ovary. Infections of the ovary are almost without exception 
secondary to tubal infection, and hence the bacteriology of ovarian 
abscesses is in most part identical to that of purulent salpingitis. 
Primary ovarian abscesses are exceedingly rare, though the possi- 
bility of infection travelling to the ovary by way of the blood-lymph 
channels or directly through the genital tract without visible effects 
until the ovary is reached cannot be denied. Sutton says that primary 



122 GENERAL DIAGNOSIS 

ovarian abscesses are always tuberculous. This statement is not 
verified by experience. Martin collected 55 cases of ovarian abscesses 
from the literature, and of this number 35 contained bacteria, 
the remaining 20 were sterile. The gonococcus and the bacillus 
coli communis were the most frequently found. Staphylococci, 
streptococci, pneumococci, and the typhoid bacillus were relatively 
infrequent. It is a rule to which there are numerous exceptions 
that bilateral infection of the appendages speaks for gonorrhoea, 
and unilateral involvement for puerperal infection. Suppurating 
ovarian cysts have been discussed by Cumston. Dermoid cysts 
are particularly liable to infection and the development of abscesses. 
The organisms above mentioned have been found in these cysts. 
Inasmuch as suppurating cysts are almost invariably adherent to 
the bowel, the colon bacillus is of common occurrence, but more 
often as a secondary infection. The size of the abscess is no criterion 
of the virulence of the pus. Fraisse removed a cyst containing 
15 litres of sterile pus. Such abscesses at one time undoubtedly 
contained either pathogenic or saprophytic organisms. The 
periodic congestion of the ovary and rupture of the Graafian follicles, 
together with the tendency of the ovary to the formation of new- 
growths and the torsion of the pedicle, render the ovary peculiarly 
susceptible to infection. 

Streptococcus and staphylococcus infections of the ovary are common. 
These infections commonly follow labor and abortion. The virulence 
of the infection and the resistance of the individual determine the 
clinical picture. The lesion in the ovary is but a part of the more 
general infection of the lower genital tract occurring at intervals of 
days, weeks, and months subsequent to the initial infection. 

Gonococcus infection of the ovaries doubtless ranks first in point 
of frequency. Reymond affirms that the gonococcus always attacks 
the surface of the ovary, and is never found in the pus of an ovarian 
abscess. The gonococcus can enter the substance of the ovary 
through the blood and lymph channels and through the open 
follicles and corpora lutea. 

The bacillus coli communis infection of the ovary is said never to 
occur in the absence of adhesions binding the ovary to the bowel. 
The infection is consequently mixed in the majority of cases. It 
is probable that the infection travels also through the genital tract 
to the ovary. 



BA CTEBIOL GICAL EXAMINA TIONS 1 23 

Pneumococcus infection of the ovary has been recorded by several 
observers. A pure culture of the pneumococcus has been obtained 
froin the pus in the abscess. In none of the cases was there a 
recent history of pnei^monia. 

Tubercle bacillus infection of the ovary is by no means so infrequent 
as the early writers would have us believe. Miliary tubercles are 
observed by the microscope which would otherwise appear perfectly 
normal. Primary infection of the ovary is most unusual. The 
infection is almost invariably secondary, but the initial infection is 
not always clear. It is generally believed that the tubes are the 
primary seat in the majority of cases. Schottlander believes the 
peritoneum to be the primary course of the infection, but does not 
exclude the tubes as a possible source. It is, of course, possible 
for the tubercle bacillus to pass from the vagina through the uterus 
and tubes to the ovary, or from the vagina through the broad liga- 
ments to the hilum of the ovary. In general miliary tuberculosis 
the ovary is especially liable to be attacked by way of the blood. 
In 48 cases of ovarian tuberculosis Orthmann traced the infection 
to the tubes in 26 and to the peritoneum in 22. 

Pelvic, Peritoneum, and Cellular Tissue. The involvement of 
the peritoneum and cellular tissues of the pelvis is almost invariably 
secondary to infections of the uterus, tubes, ovaries, cervix, vagina, 
bladder, or rectum. The bacteriology of pelvic cellulitis and peri- 
tonitis is therefore that of vaginitis, metritis, salpingo-ovaritis, 
cystitis, and proctitis. In puerperal infection the streptococcus and 
staphylococcus are about equally liable to infect the pelvic cellular 
tissue and peritoneum. Not so with the gonococcus and tubercle 
bacillus, which attack by preference the peritoneum. The colon 
bacillus and tubercle bacillus doubtless very frequently pass through 
the bowel to the peritoneum and cellular tissue, though with these 
organisms as with all others the usual avenue of infection is the 
genital tract. 



PART II. 

SPECIAL DIAGNOSIS. 



CHAPTEE XVII. 

THE DIAGNOSIS OF UTERINE PREGNANCY.^ 

While it is not the purpose of the author to enter into a dis- 
cussion of purely obstetric subjects, yet the diagnosis of pregnancy, 
both normal and pathological, is such an essential part of the 
diagnosis of diseases of women that it will not be out of place to 
present the following outline. 

For convenience of description the term of pregnancy will be 
divided into trimesters, and in each trimester will be given the 
subjective and objective signs of pregnancy, together with their 
fallacies, and, finally, the diagnostic value of each sign. 

FIRST TRIMESTER. 

I. Subjective Signs. 

1. Cessation of Menstruation. 
a. Physiological fallacies: 

(1) Pregnancy may occur before the first menstruation. 

(2) Pregnancy may occur after the menopause. 

(3) Pregnancy may occur during the period of lactation. 

(4) Menstruation rarely persists after conception for more 

than one or two months. 

(5) Menstruation may recur but once in two or more 

months. 



^ The outlines here presented are largely taken froin the author's notes when a student of 
the late W. W. Jaggard. 

(125} 



126 



SPECIAL DIAGNOSIS 



h. Pathological fallacies: 

(1) The menstrual flow may be simulated during pregnancy 
by hemorrhage caused by metritis, erosions of the 
cervix, cancer, hydatid mole, placenta prsevia, ectopic 
pregnancy, and premature detachment of the placenta. 



Fig. 31 





Breast of virgin, showing pink areola and position of gland. (Dennis.) 

(2) Causes other than pregnancy may result in amenorrhoea 
— i. e.y changes of climate and environment, general 
wasting diseases, mental disturbances, and patho- 
logical lesions of the uterus and ovaries. 



PLATE XVIII. 




Breast of Dark Brunette, Near Term. 

From Life. (Jewett.) 



PLATE XIX. 






Breast of Blonde in Later Months of Ppegnaney. 

I'^roii) Life f ]r\\'('ti ) 



THE DIAGNOSIS OF UTERINE PREGNANCY 



127 



Value of the Sign. In a woman of the childbearing period who 
has previously been regular cessation of menstruation is a highly 
probable sign. 

2. Morning sickness occurs commonly between the fourth and 
eighth weeks; earUer and more frequent in primiparse. 



Fig. 32 





Breast of woman who had been pregnant, show^ing pigmented areola and position of 

gland. (Dennis.) 

Fallacies: 

(1) Diseases of the brain, kidney, and digestive tract. 

(2) Uterine displacements. 

(3) New-growths of the uterus and ovaries. 

Value of the Sign. Highly presumptive when associated with 
amenorrhcea. 

3. Salivation. Rarely present after the fourth week, and is 
of no special value as a sign of pregnancy. 



128 SPECIAL DIAGNOSIS 

4. Nervous Phenomena. 

(a) Ringing in the ears: rarely present. 
(6) Neuralgia: rarely present. 
(c) Changes in disposition. 
Value of the Sign. Negative. 

5. Irritable bladder, due to the size and weight of the uterus. 
Value of the Sign. Negative. 

II. Objective Signs. 

1. Changes in the Mammary Glands. At the end of the 
fourth week the breasts tingle and enlarge; at about the twelfth 
week there is pigmentation and enlargement of the areola, promi- 
nence of the glands of Montgomery, the nipples enlarge, become 
erectile and sensitive, veins stand out prominently under the skin, 
a secondary areola forms, linea albicantes are sometimes seen near 
the areola, and colostrum is secreted. (See Plates XVIII. and XIX.) 

Fallacies: 

(1) Breasts may enlarge from pelvic tumors. 

(2) Breasts may enlarge during menstruation. 

(3) Prostitutes and multiparse may have a secretion of colostrum. 

(4) Multiparae retain some of the above signs, and little or no 

change may occur during pregnancy. 
Value of the Sign. Highly presumptive, especially in young 
primiparoB. 

2. Discoloration of the vulva and vagina may occur as 
early as the sixth week or as late as the eighth month. The struc- 
tures soften and become blue in color from venous congestion. 
Discoloration varies in degree and in time of appearance. 

Fallacies: 

(1) Frequently observed in fleshy women. 

(2) Caused by all new-formations and inflammatory swellings 

in the pelvis. 

(3) May be due to portal congestion from diseases of the heart, 

lungs, liver, kidney, etc. 
Value of the Sign. Presumptive. 

3. Softening of the vaginal portion of the cervix gener- 
ally begins at the fourth week, earlier in multiparse. It is due to 
passive congestion. The softening begins at the external os and 
extends upward* 



THE DIAGNOSIS OF UTERINE PREGNANCY 



129 



Fallacies: Same as for discoloration of the vulva and vagina. 
Value of the Sign. Highly presumptive. 



Fig. 33 




Bimanual examination for compressibility of the isthmus at the sixth week. (Jewett.) 

Fio. 34 




Retroversion of a pregnant uterus, with fixation by adhesions binding the fundus to the 

rectum and sacrum. 



130 



SPECIAL DIAGNOSIS 



4. Softening and Compressibility of the Lower Uterine 
Segment- (Hegar's Sign). Elicited by introducing one or two 
fingers into the posterior vaginal fornix and approximating the 
fingers of the hand over the abdomen as closely to the fingers in 
the vagina as possible. The lower uterine segment may be com- 
pressed to the thinness of paper. 

Hegar's sign may be elicited as early as the sixth week. The 
sign may be impossible of demonstration, because of the thickness 



Fig. 35 




Anteversioflexion of the pregnant uterus at the end of the third month of pregnancy. 



and rigidity of the abdominal wall. Rectal palpation will be of 
service in these cases. 

Value of the Sign. Very reliable, though not a positive sign of 
pregnancy. 

5. Leucorrhcea often begins early and persists throughout 
pregnancy. 

Value of the Sign. Negative. 



THE DIAGNOSIS OF UTERINE PREGNANCY 131 

6. Changes in Position, Size, Form, and Consistency of 
THE Uterus. 

(a) Position: extreme anteversion. 

(h) Size of child's head at end of third month. 

(c) Form: increase in the anteroposterior diameter, becoming 

spherical at the end of the third month. 
{d) Consistency: soft and elastic. 
Value of the Sign. Highly 'presumptive. 

There are no positive signs of pregnancy in the first trimester except 
seeing the fetal structures and decidua, hut when two or more of the 
above-named presumptive or highly probable signs are present the 
diagnosis of pregnancy amounts to a moral certainty. 



SECOND TRIMESTER. 

I. Subjective Signs. 

1. Cessation of menstruation continues. 

2. Morning sickness rarely persists after the fourth to the 
fifth month. 

3. Salivation rarely continues. 

4. Nervous phenomena may increase. 

5. Bladder may be less irritable. 

6. Active Fetal Movements. Time of occurrence, six- 
teenth to eighteenth week — earlier in multiparse. Likened to 
the fluttering of a bird in the hand, and increase in force with 
time. 

Fallacies: 

(1) Peristaltic movements of the bowel. 

(2) Spasmodic contractions of the abdominal muscles. 

(3) Movements of abdominal tumors. 

Value of the Sign. Presumptive. Of value in determining the 
date of confinement. Count forward twenty-four weeks in prim- 
iparse, twenty-three weeks in multiparse. 

II. Objective Signs. 

1. Active Fetal Movements. A certain sign of pregnancy 
when felt and heard by the physician. 



132 



SPECIAL DIAGNOSIS 



2. Passive fetal movements (ballottement) are first elicited 
about the sixteenth week. Ballottement may be: 

(a). Internal: Hands are placed as in an abdominovaginal 
examination. With the hand on the abdomen a sharp 
tap is given; the fetal body is felt to bound and 
rebound. 
(6) External: The hand is placed flat upon one side of the 
abdomen, the opposite side is sharply tapped with the 
fingers of the other hand. 
Fallacies : 

(1) Pedunculated tumors floating in ascitic fluid. 

(2) Stone in the bladder. 

(3) Floating kidney and spleen. 

Value of the Sign. Positive in competent hands. 



Fig, 36 




\^Xi I 



J.— ^— -v^ 



Internal ballottement (seniireeumbent posture) at sixth month. (Jewett.) 

3. Direct Palpation of the Fcetus. 
Value of the Sign. Positive. 

4. Intermittent Uterine Contractions. The time of 
appearance is between the tenth and sixteenth week. The uterus 
becomes firmer and assumes a pear shape, then slowly relaxes. 
The intervals between contractions are from five to twenty 
minutes. 



m 



THE DIAGNOSIS OF XJTEBINE PREGNANCY 133 

Fallacies: 

(1) Contractions of the recti muscles. 

(2) Contractions of soft fibroids. 

(3) Intermittent uterine contractions in hsematometra, pyo- 

metra, and hydrometra. 
Value of the Sign. Positive. 
5. Auscultation. 

(a) Fetal Heart Tones. Heard in the fourteenth to the 

eighteenth week. The condition governing the 
intensity of the heart tones are: 

a. Position of the foetus: heart tones increased when 

the child's back presents. 

b. Position of the placenta: heart tones decreased 

when auscultating through the placenta. 

c. Size of child: heart tones strong in proportion to 

the development of the child. 

d. Thickness of the abdominal walls obscures the fetal 

heart tones. 

The heart tones resemble the tick-tack of a watch under a pillow. 
The frequency is 100 to 150 a minute. Temperature and exercise 
increase and uterine contractions slow the heart beat. 

Value of the Sign. Most reliable of all signs, not only showing the 
fact of pregnancy, but also the life of the foetus. 

(b) Fetal Souffle. A soft, blowing sound synchronous with the 

fetal heart beat occurs in 14 to 16 per cent, of all cases. 
The sound is caused by the circulation in the cord, and is 
said to be due to an abnormally short cord or one that is 
twisted, knotted, or wound about the neck of the child. 
Value of the Sound. Positive when heard. 

(c) Placental Souffle. A soft, blowing sound synchronous with 

the maternal heart beat. The intensity is decreased dur- 
ing uterine contractions. The sound is not constant in 
rhythm or intensity, and is best heard on the left side 
of the uterus. The time when first heard is between 
the fourteenth and eighteenth week. 
Fallacies: 

(1) Heard in vascular tumors of the pelvis. 

(2) Gas in the mother's bowels. 

(3) Murmurs in the arteries of the pelvis. 



134 SPECIAL DIAGNOSIS 

Value of the Sign. Probable. 

6. Rate of Growth of the Uterus. 

Value of the Sign. Positive in experienced hands. No other 
tumor grows so steadily and rapidly. 

7. Changes in Position, Size, Form, and Consistency of 
THE Uterus. 

(a) Position: median. 

(6) Size: end of the third month, at the level of symphysis 
pubis. 
End of the fourth month, three finger-breadths above 

symphysis pubis. 
End of the fifth month, two-thirds the distance from 

the pubes to the umbilicus. 
End of sixth month, at the level of the umbilicus. 
(See Fig. 37.) 

(c) Form: globular. 

(d) Consistency: soft and elastic. 

Value of the Sign. Positive in experienced hands. 

THIRD TRIMESTER. 

I. Subjective Signs. 

1. Cessation of Menstruation continues. 

2. Morning sickness rarely persists. 

3. Salivation rarely persists. 

4. Nervous phenomena may be increased. 

5. Active fetal movements increase and may seriously annoy 
the mother. 

II. Objective Signs. 

1. Active fetal movements increased. 

2. Passive fetal movements increased. 

3. Direct palpation of the foetus usually accomplished 
with ease. 

4. Intermittent uterine contractions marked. 

5. Auscultation of fetal heart, fetal and uterine souffle 
increasingly distinct. 

6. The rate of growth of the uterus continues as in second 
trimester. 



THE DIAGNOSIS OF UTERINE PREGNANCY 



135 



7. Position of the uterus at the end of the seventh month 
is one-third the distance from the umbihcus to the ensiform 
cartilage; at the end of the eighth it is two-thirds the distance; 
at full term it has dropped back to the level of the eighth month. 

8. Changes in the Form of the Uterus. The lower uterine 
segment thins and distends; the cervix becomes effaced from above 
downward. 

Fig. 37 




^andlO 



Showing the level of the fundus from the fourth to the tenth month. 

9. Changes in the Contour of the Abdomen. Until the 
end of the ninth lunar month the abdomen shows a regular curve. 
When the head sinks into the pelvis the epigastrium is flattened 
and the abdomen protrudes more prominently. 

10. Presentation of part or all of the fetal parts is 
the last and most conclusive sign of pregnancy. 

DIAGNOSIS OF THE LIFE OR DEATH OF THE FCETUS. 



Foetus is Known to Be Living When the Physician: 

1. Hears the fetal heart or fetal souffle. 

2. Feels the fetal movements. 



136 jSPHcial diagnosis 

Foetus is Believed to Be Dead When : 

1. Fetal movements cease after having been felt by the physician. 

2. Fetal heart tones cease after having been heard by the 
physician. 

3. Temperature of the vagina is lowered. 

4. Foetus loses its normal elasticity. 

5. Colored liquor amnii is discharged. 

6. Head of the child is softened. 

7. Mother loses flesh, breasts diminish in size, and there is 
general malaise. It is to be remembered that a dead foetus may 
lie in the uterus weeks and months after full term. 



DIAGNOSIS OF THE TIME OF PREGNANCY AND PREDICTION 
OF THE DATE OF CONFINEMENT. 

The exact time of conception is rarely known, hence it is impos- 
sible to fix the exact date of confinement. The duration of normal 
pregnancy varies within wide limits. Pregnancy may be accidentally 
terminated by a fall, diarrhoea, shock, etc. The normal limits are 
placed at two hundred and forty to three hundred and twenty days. 

Data for Determining the Date of Confinement: 

1. From the date of a single coition count forward two hundred 
and seventy-two to two hundred and seventy-five days. 

2. From the first day of the last menstrual period count back- 
ward three months and add seven days. 

3. From the time of ^'quickening" count forward twenty-three 
weeks in multiparse and twenty-four weeks in primiparse. 

4. From the level of the fundus. (See Fig. 37.) 

5. From the size of the foetus — an uncertain method requiring 
long experience. 

Diagnosis of Multiparity. It may not be possible to say with 
certainty that a woman has given birth to a child. The following 
are the anatomical evidences of previous childbearing : 

1. Rupture of the Hymen and Perineum. The hymen may be con- 
genitally absent; it may not rupture in labor, but is usually ruptured 
in coitus, masturbation, and operations upon the lower genital tract. 

2. Laceration of the Cervix. The cervix may not be lacerated in 
labor, but may be by dilating for intrauterine explorations and 
operations. 



THE DIAGNOSIS OF UTERINE PREGNANCY 1^7 

3. Lacerations of the perineum, when direct violence can be 
excluded, are regarded as positive evidences of multiparity. 

4. Lacerations of the Vagina. When direct violence and opera- 
tions upon the vagina can be excluded scars in the vaginal mucosa 
are regarded as evidences of multiparity. The smoothing out of 
the rugosities may be due to masturbation and coition, and cannot 
be regarded as conclusive evidence of multiparity. 

5. Mammary glands are pigmented, flabby, and show the striae 
gravidarum in a multipara; but these evidences are not always 
present, and, on the other hand, they may be present to a greater 
or less degree in women who have not borne children.* 

6. Striae gravidarum are commonly found on the abdominal wall 
and thighs. They are the result of stretching of the skin from a 
growing tumor, and hence may result from abdominal distention 
from whatever cause, not only in multiparas, but also in prim- 
iparae, and in the male as well as in the female. While suggestive 
of pregnancy, they cannot be regarded as positive evidence. 

DIAGNOSIS OF MULTIPLE PREGNANCY. 

1. Unusually large uterus may be due to hydramnios, hydatid 
mole, large foetus, and uterine tumors complicating pregnancy. 

2. Groove in the fundus separating the foetuses. This is an 
unusual finding. 

3. Palpation of Two Heads or of Two Breeches. A positive 
evidence when elicited. 

4. Fetal heart tones heard in two separate areas and not 
synchronous. 

5. Vaginal touch, demonstrating two separate and distinct pre- 
senting bodies — i. e., two heads, two breeches, or a head and a 
breech, or two separate and distinct protruding bags of membranes. 

6. Mensuration of the foetus, showing an abnormally long 
measurement for a single foetus. 

DIAGNOSIS OF THE CAUSES OF HEMORRHAGE OCCURRING 

DURING PREGNANCY. 

Any of the causes of hemorrhage from the non-gravid uterus 
(see page 30) may operate during pregnancy. W^e must, therefore, 



138 SPECIAL DIAGNOSIS 

carefully distinguish between hemorrhage due to pregnancy alone 
and one resulting from some complication of gestation. In so 
doing we must exclude the possible existence of inflammatory 
lesions, of benign and malignant new-formations, of ulcers and 
erosions of the cervix. 

It is often only with the greatest difficulty that we are able to 
determine the source of hemorrhage from the pregnant uterus. 
According to Winter, endometritis is the most frequent source. 
With the foetus in utero it is manifestly impossible to say with 
absolute certainty that endometritis exists. This fact is due to the 
unreliable symptoms, to the absence of any definite physical signs, 
and, finally, to the impossibility of demonstrating, by microscopic 
examination of scrapings, the characteristic histological changes in 
the decidua before the termination of pregnancy. We are, there- 
fore, compelled to rely upon the history of endometritis previous 
to pregnancy and upon the exclusion of other possible causes. A 
negative history does not exclude the possibility of endometritis, 
because endometritis may exist without symptoms and without 
apparent cause. 

The long continuance of the hemorrhage, the admixture of mucus 
with blood, and the habit of habitual abortion are suggestive of 
endometritis, but a positive diagnosis is only made by a micro- 
scopic examination of the decidua after expulsion of the egg. 

Placenta prsevia as a cause of hemorrhage occurring during 
pregnancy is a most important factor from a clinical point of view. 
Hemorrhage from placenta prsevia rarely occurs in the early months 
of pregnancy, and the liability increases up to the time of labor. 
The first loss of blood generally occurs after the eighth month. 

A characteristic feature of hemorrhage from placenta prsevia is 
said to be its occurrence in the intervals between uterine contrac- 
tions. The loss of blood may be instantly fatal or may slowly 
exhaust the patient's strength. The diagnosis rests upon establish- 
ing the fact of pregnancy and upon the physical evidences of a 
misplaced placenta. Under favorable conditions the edge of the 
placenta may be palpated through the vaginal wall. In a con- 
joined examination the fetal parts are indistinctly felt through the 
vagina, and ballottement may be impossible of demonstration. It 
is only possible to recognize placenta prsevia by feeling the placenta 
through the dilated cervix. The characteristic stringy feel of the 



THE DIAGNOSIS OF UTERINE PREGNANCY I39 

placenta is noted. An incomplete placenta prsevia is recognized by 
sweeping the finger between the margin of the placenta and the sides 
of the cervix. In complete placenta prsevia this would be impos- 
sible. 

Hemorrhage from premature separation of a normally situ- 
ated placenta (accidental hemorrhage, ablatio placentae — Holmes) 
may occur late in the period of pregnancy or in labor. The hemor- 
rhage is apparent or concealed. In concealed hemorrhage it is 
possible for death to occur without the blood finding its way out 
through the cervix. 

In making a diagnosis of the cause of the hemorrhage, placenta 
prsevia and rupture of the uterus must be excluded. The former 
can only be excluded by palpating or failing to palpate the placenta 
through the dilated cervix; the latter is excluded from the fact that 
it occurs late in labor, the uterus diminishes in size, and a new 
abdominal tumor arises. 

In concealed hemorrhage there is, in addition to the usual general 
signs of internal hemorrhage, a sudden increase in the size of the 
uterus; cessation or obscurity of the fetal movements and heart 
tones, and, finally, in place of the soft, elasticity of the normal 
pregnant uterus, there is a boggy consistency. Sometimes a mass 
of fibrin within the cervix may feel much like placenta, and can 
only be recognized with certainty by the aid of the microscope. 

THE DIAGNOSIS OF ABORTION. 

We may speak of abortion in progress, of incomplete abortion, 
and of complete abortion. In making a diagnosis of abortion we 
must first establish the fact of pregnancy. ■ This is not always 
possible in early abortion without the presentation of part or all of 
the fetal structures. 

When hemorrhage from the uterus is associated with painful 
uterine contractions the diagnosis of pregnancy is most probably 
correct. An irregular hemorrhage following upon a period of 
amenorrhoea in a woman sexually mature is always suggestive of 
pregnancy, and when the uterus corresponds to that of pregnancy 
the diagnosis of incomplete or threatened abortion is made with 
certainty. Through the dilated cervix it may be possible to see or 
to feel the presenting part of the ovum. 



140 SPECIAL DIAGNOSIS 

The diagnosis of an abortion is manifestly more difficult when it 
is not certain that pregnancy has existed. This difficulty arises 
in abortion of the second month, when the expected menses are 
delayed and there follows a hemorrhage unlike the menstrual flow 
in appearance and in amount. That pregnancy exists is suggested 
by the period of amenorrhoea, the softening and discoloration of the 
cervix, the slight enlargement and softening of the uterus, and the 
discoloration of the vagina and vulva. These evidences of preg- 
nancy, together w^ith the unexpected appearance of a uterine 
hemorrhage, are all but conclusive proofs of an abortion. All 
blood expelled should be carefully searched for fetal tissue. 

After establishing the fact of pregnancy and of abortion, it then 
becomes imperative to determine whether the abortion is complete 
or incomplete. With but few exceptions the hemorrhage will con- 
tinue as long as the uterus is not thoroughly emptied, and will 
cease the moment all the fetal structures are expelled. The uterus 
rarely contracts firmly so long as fetal structures remain in the 
uterus; and the patient's health is likely to be influenced by exces- 
sive discharges. When putrefactive changes take place in the fetal 
remains the presence of a malignant growth or sloughing fibroid 
may be suspected where pregnancy is not considered possible or 
probable. Mistakes will often be prevented by bearing in mind 
the possibility of pregnancy in every case of delayed menstruation 
followed by protracted hemorrhages, foul-smelling discharges, and 
an enlarged, softened uterus. 

It is to be remembered that in some women there is a periodical 
flow of blood for one, two, or more months after conception. We 
may say with certainty that abortion is complete when the expelled 
ovum is intact, or after a digital or instrumental exploration of the 
uterine cavity. We may say with certainty that abortion is incom- 
plete when only a portion of the ovum is known to have been 
expelled or when fetal remains are found in the uterus by explor- 
ing with the finger or instruments. 

THE ANATOMICAL DIAGNOSIS OF PREGNANCY. 

The diagnosis of pregnancy may not be made with certainty from 
the subjective and objective signs. There may be a complete 
absence of all subjective symptoms, or the patient may deny their 



THE DIAGNOSIS OF UTERINE PREGNANCY 141 

existence. Again, an early abortion may not be recognized by the 
patient as such, and the diagnosis must rest upon the macroscopic 
and microscopic examination of expelled masses and membranes 
or of scrapings removed by the finger or curette. 

The macroscopic diagnosis of pregnancy is made from naked- 
eye inspection of particles removed from the uterus — i. e., chorionic 
villi, decidua, fetal body. It is not always possible to recognize 
these structures with certainty by the unaided eye, and in such 
cases the microscope is indispensable. 

Fig. 38 









<S^^«^. 



<S:/ 



*^.<»:r-. *->^. Si ^ -®* 






* I 



r, 



^^.^ ''' ,^,t^^^V ^. 






Scrapings from a puerperal uterus. Chorionic villi and decidua are seen. There are no 

degenerative changes. 

The microscopic diagnosis of pregnancy is largely based upon 
the finding of chorionic villi and decidual cells. These are composed 
of a connective-tissue framework in which are found fetal blood- 
vessels. The connective tissue is composed of round, spindle-shaped 
or stellate-shaped cells, with an intercellular mucinous substance 
identical to that of Wharton's jelly in the umbilical cord. Fibrillar 
processes join the cells forming a network. The bloodvessels 



142 



SPECIAL DIAGNOSIS 



coursing through the stroma are endotheUal-Hned canals in the 
early weeks of pregnancy; later they acquire a muscular wall. As 
pregnancy advances the embryonic connective-tissue cells become 
matured into fibres forming a more compact stroma. The epithelial 
coverings of the villi in early pregnancy are composed of two 
distinct cellular layers. The innermost layer is that of Langhans, 
forming a single or double row of spindle-shaped cells immediately 



Fig. 39 









■■^ j#^-.i- 






■ ■■A 



?««««»» 






'^c J i * 


















..^ 



"^%k; 






^-^ 






i^' 






X'* 



■tv ; ^'i?*, ^-.y^,' j-J ^n- ,ti\. 



Decidua of early pregnancy. The glands are large, irregular, and lined by a single layer 
of columnar epithelium. The interglandular connective tissue is relatively scant. 



covering the stroma. In the early months of pregnancy Langhans' 
layer is clearly defined, but in the later months it may wholly lose 
its identity. 

Overlying Langhans' layer is the syncytium, an irregular band 
of protoplasm containing many nuclei and vacuoles. The nuclei 
are round or oval, and take a deep stain. The protoplasm is finely 
granular and contains vacuoles of considerable dimensions. Giant 
cells and buds spring from the syncytium, particularly at the top of 



PLATE XX. 



?^;:-';,^' .-. ■■ -^ ' -^■•>j>'. "" ^-^ '- '" -■ .o^W^' ' .-'""■■^.■^^;>'-'''^->' ' - ;-:^-/".«'- :V.;„:V;^'i-^.v?;'.;vi: 






t^;.: 



^^■^•:v^* 










*^ Placental ShadoAArs." 

The section represents placental tissue scraped from the uterus ten ^^^eeks 
after an abortion. The degenerated, villi are shown as "shadows." Islets of 
old blood are seen between the villi. 



THE DIAGNOSIS OF UTERINE PREGNANCY 143 

the villus; these also contain nuclei and vacuoles. The syncytium 
and Langhans' layer may wholly disappear and the connective 
tissue undergo partial degeneration when retained in the uterus for 
a considerable time. The term ''placental shadows" is applied to 
such a condition. (See Plate XX.) 

The "presence of chorionic villi in discharged membranes is proof 
positive of a uterine pregnancy. 

The decidua may be regarded as the endometrium of pregnancy. 
It is, therefore, a maternal structure. The endometrium becomes 
thickened even to tenfold. This thickening is due to an increase 
in size of the various elements of the endometrium. From the 
beginning of pregnancy the connective-tissue cells of the mucosa 
increase in size four and even six times their original proportions. 
This growth is due more to an increase in the cell protoplasm than 
to the cell nuclei. These hypertrophied connective-tissue cells are 
known as decidual cells. In form they closely resemble squamous 
epithelium. The connective-tissue spaces are almost wholly oblit- 
erated by compression. 

Veins and arteries which in the mucosa of a non-gravid uterus 
are scarcely visible, in the decidua are large blood channels and 
spaces. 

It is most important to consider the changes in the glands. They 
become greatly enlarged and tortuous. Near their outlet the 
surrounding decidual cells compress the gland, and deeper in the 
decidua the glands are tortuous and enormously increased in size. 
These glandular changes divide the decidua into a compact and 
spongy layer. Above is the compact layer, where the glands are 
compressed and the decidual cells are closely packed together; 
below is the spongy layer, where the decidua is honeycombed by 
distended, tortuous glands. In the expulsion of the placenta the 
line of cleavage is within the compact layer. The regeneration of 
the glands and surface epithelium originates in the gland epithelium 
of the spongy layer. 

The epithelium of the glands is transformed from the cylindrical 
type to the cubical or flattened, containing but little cell protoplasm 
and closely resembling squamous epithelium. Many layers of 
squamous epithelium have been observed. It is evident that a 
diagnosis of glandular endometritis or of malignant adenoma might 
be made where pregnancy is unsuspected. 



CHAPTER XVIII. 

THE MICEOSCOPIC DIAGNOSIS OF EXPELLED MEMBKANES 

FROM THE UTERUS. 

Decidua of Intrauterine Pregnancy. 
Decidua of Extrauterine Pregnancy. 
Decidua of Menstruation. 
Unorganized Membranes. 
Organized Membranes. 

The physician will be called upon to determine the nature of a 
membrane or mass spontaneously expelled from the uterus. Here 
the microscope is indispensable to a positive diagnosis. It is of 
prime importance to first determine whether or not the membrane 

Fig. 40 




Oast from uterine cavity in exfoliative endometritis, membranous dysmenorrhoea, natural 

size. (After Costa.) 

is organized. Placing the membrane in cold water, if it becomes 
friable and disintegrates it is unorganized. Under the microscope 
a fibrinous structure is seen, in the meshes of which are blood cells 
in all stages of disintegration. Calcareous concretions may be ex- 
pelled spontaneously or removed by the curette. They probably come 
from calcareous deposits in mucous polyps or submucous fibroids. 
(144) 



MICROSCOPIC DIAGNOSIS OF EXPELLED MEMBRANES 145 

Of the organized structures, we will consider the decidua of intra- 
uterine pregnancy, the decidua of extra-uterine pregnancy, the 
decidua of menstruation, and the vesicles of hydatiform mole. 

MEMBRANOUS DYSMENORRH (EA (EXFOLIATIVE ENDO- 
METRITIS). 

Because of the occurrence of menstruation accompanied by a 
discharged membrane and great pain the condition is spoken of 
as membranous dysmenorrhoea; but since the discharged mem- 
brane does not resemble that of the uterine mucosa during men- 
struation, but does very closely resemble interstitial exudative 
endometritis, a better term to employ would be exfoliative endome- 
tritis. This does not imply that the lesion is necessarily inflam- 
matory in origin, inasmuch as there are no known facts to sub- 
stantiate such an assertion. Nothing definite is known of the 
cause of this lesion. 

The first clinical observations were made in 1723 by Morgagni. 
When the existence of pregnancy can be excluded beyond all 
possible doubt a clinical diagnosis is made. Where there is any 
possibility of pregnancy a positive diagnosis can only be made by 
a microscopic examination of the discharged membrane, and even 
here difficulties will arise because of the presence of large con- 
nective-tissue cells resembling decidual cells. 

Macroscopic Examination. The membrane rarely appears as a 
complete cast of the uterus. In form it is triangular, presenting an 
opening at each angle — i. e., the internal os and the uterine ends 
of the Fallopian tubes. The outer surface is shaggy and of a dull- 
gray color; it is sometimes overlaid with a coagulum of blood. 
Opening the sac nothing is found within to suggest fetal remains. 
The inner surface is smooth and presents numerous small openings 
which represent the mouths of glands. The membrane is 1 to 3 
mm. thick. 

Microscopic Examination. In general the membrane may be said 
to resemble exudative interstitial endometritis. The surface epithe- 
Hum may be intact or partially or wholly lost. The glands are 
irregularly compressed and widely separated. A rather character- 
istic feature is the zigzag course of the glands. The stroma is more 
or less crowded with small round cells. In the lower strata are 
frequently seen large connective-tissue cells which closely resemble 

10 



146 



SPECIAL DIAGNOSIS 



decidual cells. The presence of these cells sometimes makes it 
difficult and at times impossible to distinguish the membrane from 
the decidua of pregnancy. C. Ruge called attention to the fact 
that decidual cells are not evidences of pregnancy; that these cells 
are found in occasional forms of endometritis. 

In exfoliative endometritis these connective-tissue cells are less 
uniformly enlarged than in the decidua of pregnancy, and upon this 
fact the diagnosis must largely be based. 

Thjj Diagnosis of Expelled Membranes. 



Clinical 
features. 



Macro- 
scopic ■; 
findings 



Micro- 
scopic 
findings. 



Decidua of intrauterine 
pregnancy. 



Symptoms and signs of 
pregnancy ; hemorrhage 
and pain accompanying 
the discharged mem- 
brane ; no extrauterine 
pelvic tumor. 



Thick shreds with shaggy 
surface, or smooth, glis- 
tening membrane. 



Decidua of extrauterine 
pregnancy. 



Surface 
epithelium. 



Glands. 



Stroma. 



Vessels. 



Fetal 
tissue. 



Seldom pres- 
ent. 



Compressed 
above, widely 

dilated and 
very irregular 
below ; epithe- 
lium flattened. 

Typical de- 
cidual cells. 



Very widely 
dilated ; walls 

composed of 
endothelium ; 

no muscula- 
ture. 

Chorionic 
villi amnion. 



Symptoms and signs of 
pregnancy; often irreg- 
ular ; hemorrhage and 
pain accompanying 
the discharged mem- 
brane ; extrauterine 
pelvic tumor. 

Rough fibrous mem- 
brane; no villous struc- 
tures; irregularities on 
inner surface. 



Flattened; may be want- 
ing. 



Changes similar to intra- 
uterine pregnancy, 
though less marked. 



Decidual cells not so 
large ; more intercellu- 
lar substance. 



Less widened blood 
spaces. 



Absent. 



Decidua of menstruation. 



No evidence of pregnancy; 
no extrauterine pelvic 
tumor. 



Unorganized. 

Fibrinous 
structure, 
external sur- 
face smooth, 
internal sur- 
face rough. 



Absent. 



Absent. 



Fibrinous 
network. 



Absent. 



Absent. 



Organized. 

Triangular 

cast of uterus, 

or bits of 

membrane ; 

surface 

smooth with 

sieve-like 

depressions. 

Cylindrical, 

rarely 

flattened or 

lost. 

Zigzag in 

their course ; 

epithelium 

cylindrical. 



Round-cell 
infiltration; 
protoplasm 
of cells in- 
creased. 

As found in 
endometritis. 



Absent. 



Decidual cells are hypertrophied connective-tissue cells. There are 
causes of hypertrophy of these cells other than pregnancy, and hence 
it is that decidual cells are not pathognomonic of pregnancy. The 
only positive evidence of pregnancy in discharged membranes is the 
presence of chorionic villi. 



CHAPTEE XIX. 

THE DIAGNOSIS OF ECTOPIC PREGNANCY.^ 

Etiology. 
Classification. 

I. Ampullar. 
II. Interstitial. 

III. Infundibular. 
Retrogressive Changes in Fcetus. 
Anatomical Changes in Tube. 
Clinical Diagnosis. 

Subjective Signs. 

Objective Signs. 
Differential Diagnosis. 

ETIOLOGY OF ECTOPIC PREGNANCY. 

1. Predisposing Causes. 1. Mechanical interference with the 
passage of the ovum through the tube from — 

(a) Tumors in and about the tube — i. e., mucous polyps, 

ovarian and parovarian cysts. 

(b) Persistence of the fetal type — small lumen and convoluted 

course of the tube. 

(c) Peritoneal bands constricting the tube and drawing it out 

of position. 
{d) Congenital anomalies in development, namely, diverticuli, 

rudimentary fimbriae. 
(e) Malpositions of the tube, either congenital or acquired. 

2. Loss of cilia arid epithelium through inflammation. 
Gonorrhoea has bee'n mentioned by Gottschalk, Braun-Ternwald 

and Bandler as a frequent forerunner of tubal pregnancy. Tuber- 
culous and puerperal infections of the tube play a less important 
but by no means insignificant role. Erich Opitz detected signs of 
inflammation in all of his 23 cases. 

^ The author acknowledges his indebtedness to J. Clarence Webster, from whose mono- 
graph on " Ectopic Pregnancy " much of the material in this chapter has been taken. 

(147) 



148 



SPECIAL DIAGNOSIS 



II. Essential Cause. While the above conditions are frequently 
present, it is a matter of common observation that tubal pregnancy 
may occur in an apparently normal tube. 

Webster affirms that in ectopic pregnancy there is a genetic 
reaction in the tube which is essential to the implantation and 
development of the ovum in the tube as truly as is a similar genetic 
reaction in the uterus essential to uterine gestation. This genetic 
reaction consists in the formation of decidual tissue. It is claimed 
by Webster that a decidua, however limited, is always to be found 
in the pregnant tube. Without a decidua the ovum would find no 



Fig. 41 




Ectopic gestation in blind accessory fimbriated extremity of the right tube. (Jewett.) 



abiding place in the tube, even in the presence of the above-named 
predisposing causes. In the event of a decidual formation in the 
tube these predisposing causes will serve to obstruct the passage of 
the ovum, making possible the implantation of the ovum in the 
tube rather than in the uterus. 

Ectopic pregnancy may occur at any time during the period of 
sexual maturity, but with the greatest frequency between the ages of 
thirty and forty. It is stated that a long period of sterility pre- 
disposes to ectopic pregnancy, probably because of the existence of 
one or more of the above-named predisposing causes. Tubal gesta- 
tion occurs five times as frequently in multiparae as in primiparse — ■ 



THE DIAGNOSIS OF ECTOPIC PREGNANCY 149 

a fact which may again be explained on the ground of the develop- 
ment of the above predisposing causes. We occasionally see 
reports of cases in which a second, third, and even fourth gestation 
has occurred in the same tube, or has occurred alternately in both 
tubes. 

Recurrence of Pregnancy in the Same Tube. Pregnancy has 
occurred the second and third time in the same tube. In a case 
of Grandin the second pregnancy was recognized only two months 
after the removal of the first gestation sac. 

H. C. Hindler^ reported a case recurring in the stump of a tube 
that was previously removed for tubal pregnancy. 

Bilateral tubal pregnancy is an exceedingly rare condition. 
Kristinus^ lately described such a case. 

Pregnancy seems as frequent in one tube as in the other. Multiple 
ectopic pregnancy is possible — that is, an ovum in either tube, a 
twin pregnancy in a single tube, a normal uterine pregnancy together 
with a tubal pregnancy, and, finally, uterine pregnancy together 
with pregnancy in both tubes. Hanna finds 69 cases of tubal 
pregnancy associated with uterine pregnancy. Vilkin reports 
68 cases in literature, in 20 of which both foetuses approached 
maturity. Simpson^ reviews the history of 113 cases, and adds 
one of his own. He gives the following classification: 

Class 1. The woman becomes pregnant while carrying the dead 
products of an ectopic gestation. 

Class 2. The ectopic and uterine gestation are both living at the 
same time. 

(a) Ectopic gestation precedes the uterine. 

(h) Ectopic gestation follows the uterine. 

(c) Ectopic and uterine gestation occur coincidentally. 

In nearly three-fourths of the cases the ovum develops in the 
ampullary portion of the tube and with about equal frequency in 
the interstitial and fimbriated portions. 

CLASSIFICATION OF ECTOPIC PREGNANCY. 

I. Ampullar Tubal Pregnancy, in which the gestation begins 
in the ampullar end of the tube. Ampullar tubal pregnancy 

^ Australian Medical Gazette, August 20, 1902. 2 Wien, klin. Wochenschr., No. 47. 

3 American Journal of Obstetrics, March, 1904. 



150 SPECIAL DIAGNOSIS 

may persist as such, or the gestation sac may rupture from the 
tube. 

1. Persistent. In rare instances the gestation in the ampulla 
may go to full term. The gestation sac is pedunculated, movable, 
incarcerated, or fixed by adhesions. When confined to the pelvis 
the uterus and ovary are crowded to the opposite side; when large 
and lying in the abdominal cavity the uterus may not be displaced. 
As a rule, the gestation sac lies at the side of or behind the uterus, 
rarely between the bladder and uterus. Adhesions may firmly 
bind the tube, uterus, and ovary- together. 

Fig. 42 




Ectopic pregnancy located in the uterine end of the tube. This might be called a tubo- 
interstitial pregnancy, inasmuch as the uterus formed a part of the gestation sac. The 
pregnancy had advanced about eight weeks. Rupture had not occurred. 



2. Rupture may occur early. The most likely exit is between 
the layers of the broad ligament, though not infrequently it ruptures 
into the free peritoneal cavity. 

(a) Suhperitoneoabdominal gestation, in which the ovum escapes 
through the lower segment of the tube between the layers of the 
broad ligament. Here the ovum may perish or go on to full 
development. Rupture usually takes place not later than the four- 
teenth week. The escape of the foetus and blood may be gradual 
or abrupt. So gradual may the process be that no general disturb- 
ance will be caused, and, on the other hand, the foetus and blood 
may be discharged in such a manner as to occasion profound shock. 
As the gestation sac enlarges the layers of the broad ligament are 



THE DIAGNOSIS OF ECTOPIC PREGNANCY 



151 



separated, the pelvic viscera are pushed to one side, the peritoneum 
is stripped from the bladder, uterus, rectum, and pelvic wall. 
Later, as the gestation sac increases in size, it burrows beneath the 
parietal and visceral peritoneum, crowding the viscera forward 
and to the side. 

The placenta may remain attached to the tube or escape with the 
foetus between the layers of the broad ligament and become attached 
to any of the raw surfaces. The tube may be stretched out over 
the gestation sac as a mere ridge. Rupture into the peritoneal 
cavity may take place at any time after the escape of the ovum 

Fig. 43 




Left Fallopian tube with ectopic gestation in diverticulum, a, a, gestation sac communicating 

with diverticulum. (Jewett.) 

and blood between the layers of the broad ligament. The danger 
to life in such an event is imminent, and immediate surgical inter- 
ference is imperative. 

Gestation Comes to an End. 1. By the Formation of a Hema- 
toma. The accumulated blood destroys the life of the foetus. 
Rupture of the tube has been known to occur after the death of 
the foetus (Braun-Fernwald). The growth of the placenta subse- 
quent to the death of the foetus is the probable cause. The lower 
the attachment of the placenta the greater the hemorrhage, and 
hence the greater liability of destroying the life of the foetus. The 
blood undermines the peritoneum, sometimes encircling the uterus 



152 



SPECIAL DIAGNOSIS 



and rectum, and displacing the viscera. Coagulation of the blood 
is rapid, and eventually complete absorption of the clots or the 
organization of the clots into adhesions follows. 

2. By Suppuration. This event is usually late. It is unusual 
for an acute abscess to follow a hsematoma of the pelvis. The 
more intimate the relation to the bowel the greater the liability to 
suppurate. If the abscess is not opened by surgical intervention it 
may become absorbed, but will almost surely find its way to a 
hollow viscus or externally through the vagina or abdominal wall. 



Fig. 44 




Ampullar tubal pregnancy. Foetus surrounded by a blood coagulum. 



Parry reports a case in which rupture occurred thirty-two years 
after the formation of an abscess. Twelve cases are recorded in 
which the foetus was discharged through the bowel. 

(h) Tuboperitoneal gestation, in which the placenta remains in 
the tube and the foetus escapes into the peritoneal cavity. The 
probability of such a condition was long held impossible. The first 
authentic case reported was that of Croom. Webster made sectional, 
dissectional, and microscopic studies of the case, and proved the 
existence of tuboperitoneal gestation beyond dispute. Webster 
holds that it is as yet unproven that a foetus can escape into the 
peritoneal cavity free of its investing membranes and then develop 
to full term; he doubts the probability of such an occurrence. 



THE DIAGNOSIS OF ECTOPIC PREGNANCY I53 

furthermore, it is as yet unproven that the early complete ovum 
can escape into the peritoneal cavity and there go on to develop. 
As stated by Webster, it is inconceivable that a villous covered 
ovum can escape into the peritoneal cavity and there await the 
development of intervillous blood spaces. 

Gestation may terminate by rupture of the tube and escape of 
blood into the free peritoneal cavity. The amount of blood lost 
may be insignificant and occasion no constitutional effects; while, 
again, the blood may instantly escape in such large amounts as to 
jeopardize the life of the mother and foetus unless surgical inter- 
vention is prompt. The consequences to the mother are, therefore, 
dependent upon the extent of the tear, the rapidity with which the 
blood is allowed to escape, and, finally, upon timely surgical inter- 




Primary intraperitoneal rupture; fifth week. Tube completely ruptured, a, ovum still 
slightly adherent to its original site. (Jewett.) 

ference. The foetus may plug the opening and prevent the escape 
of much blood, or the blood may escape at intervals and eventually 
assume large proportions without seriously depressing the patient. 
(See Plate XXI.) 

Interrupted hemorrhage may also be due to contraction and 
retraction of the tube and bloodvessels. Though the quantity of 
blood lost in an interrupted hemorrhage may be equally as great as 
in the immediate escape of blood, the effect upon the mother is far 
less serious. The later in pregnancy the rupture occurs the more 
serious the consequences, because of the unusual size of the rent, 
the failure of the muscular wall to retract, the presence of large 
blood sinuses, and the failure on the part of the foetus to be 
absorbed. 



154 SPECIAL DIAGNOSIS 

Prior to the end of the second month, if rupture takes place, the 
hemorrhage will usually not be great, and the foetus will almost 
certainly be absorbed. Rupture has been known as early as the 
second week. The time of greatest frequency for rupture to occur 
is from the sixth to the fourteenth week. The greatest number 
rupture in the second month. 

The escaped blood accumulates in the most dependent portion 
of the pelvic cavity. There it is rapidly coagulated, and is later 
absorbed, suppurates, or is organized. 

Fritsch says there is no case of pelvic hsematocele in which 
ectopic pregnancy can be positively ruled out; while, on the other 

Fig. 46 




-^ 



Tubal abortion. A large intraperitoneal hemorrhage occurred in the second month of 
pregnancy. The tube is dark red and larger than a man's thumb. From the abdominal end 
of the tube a blood coagulum is seen to escape. 

hand, such authorities as Kober and Freund have reported cases. 
It is unusual for acute peritonitis to follow the development of a 
hsematocele, though it is the rule for peritoneal adhesions to form 
about the mass of escaped blood. 

Gestation May Be Destroyed. 1. By the Event of Tubal 
Abortion. By tubal abortion is meant the escape of the ovum 
through the fimbriated end of the tube into the peritoneal cavity. 
This implies that the tube must be patent at its fimbriated end. 
According to Dobberts, tubal abortion is three to four times as 
frequent as rupture of the tube. All authorities agree that it is 
much more frequent than rupture of the tube. The contractions 
of the tube expel the ovum, forcing it in the direction of least resist- 
ance. The nearer the attachment of the ovum to the fimbriated 



THE DIAGNOSIS OF ECTOPIC PREGNANCY 



155 



end of the tube, the greater the habihty to abortion. Hemorrhage 
is rarely considerable. The author removed two gallons of blood 
from the peritoneal cavity as the result of tubal abortion. All that 



Fig. 47 




Intrialigamentary rupture of a tubal pregnancy. Rupture at the isthmus, with escape 

of the foetus. 



has been said of tuboabdominal gestation in reference to the fate 
of the mother and ovum applies to tubal abortion, though with 
less force. The hemorrhage is rarely so great and the foetus is 
usually absorbed. Hence the mother may and indeed often does 
suffer but httle (Fig. 46). 

2. By the Formation of a Mole. The foetus dies and is 
preserved in its entirety, forming a fleshy mole. The death of the 
ovum is caused by an escape of blood into the fetal membranes. 
At first the mass appears like a fresh, firm, blood clot. Later it 
organizes and becomes paler as the blood absorbs and organizes. 



156 SPECIAL DIAGNOSIS 

3. By the Formation of an Abscess. Secondary infection of 
the ovum and escaped blood, as a rule, occurs through the bowel. 
In this manner a pyosalpinx may be formed, leaving no trace of 
pregnancy. 

4. By the formation of an adipocere, a lithop^dion or 
MUMMY, where the foetus is far advanced in its development. 

II. Interstitial tubal pregnancy, in which that portion of the 
tube lying within the uterine wall encloses the gestation sac. This 
is an unusual location. There may be tubouterine pregnancy, in 
which the ovum lies partly within the interstitial portion of the 
tube, partly within the uterine cavity. Again, the ovum may first 
develop within the interstitial portion of the tube, and later be 
expelled into the cavity of the uterus ("tubal abortion"). The 
gestation sac forms a part of the uterine tumor, and lies within the 
attachment of the round ligament — all other forms of tubal preg- 
nancy lie external to the round ligament. Interstitial pregnancy 
may go on to full term; the foetus may die at any period of its 
development, or, finally, rupture of the tube may permit the ovum 
to escape into the uterine cavity, between the layers of the broad 
ligament, or directly into the peritoneal cavity. In any event, the 
resulting hemorrhage may be fatal. 

III. Infundibular tubal pregnancy, in which the ovum is found 
in the infundibulum. This is an unusual condition. The behavior 
is similar to that of ampullar pregnancy. The tube is likely to 
adhere to surrounding structures, and by adhering to the ovary a 
tubo-ovarian pregnancy becomes possible. 

RETROGRESSIVE CHANGES IN A DEAD FCETUS. 

1. Mummification is a process of desiccation, the water being 
extracted from the foetus. In addition a deposit of earthy salts is 
often superimposed. 

2. Calcification, in which the fetal membranes and placenta and 
rarely the superficial parts of the foetus are permeated and incrusted 
with lime salts. There is rarely formed a dense incrustation. It 
is not uncommon for an adhesive peritonitis to be set up about the 
lithopsedion. The petrified ovum may remain in the tube, in the 
peritoneal cavity, or between the layers of the broad ligament for 
years without creating serious disturbance. Well-formed children 



PLATE XXL 




Secondary Abdominal Pregnancy at Eight Months, 

Primarily Tubal. 

The primary attachment of the placenta is plainly discernible at the 
original tubal site. After rupture the placenta grew and became attached to 
a large surface on the anterior abdominal wall. The child AA^as delivered 
through a retrouterine vaginal incision. (Jewett. ) 



THE DIAGNOSIS OF ECTOPIC PREGNANCY I57 

may be born while the parent still carries a lithopaidion. Death 
may result from peritonitis. 

3. Adipocere formation, in which the ovum is converted into 
a soap-like mass. Calcareous deposits may be found in the 
adipocere. 

4. Gangrene of the fcetus may result, and if surgical inter- 
ference is not instituted death from septic infection and peritonitis 
will follow. 

It is possible for a perfectly healthy and well-formed child to be 
delivered by surgical means, but, as a rule, the foetus is poorly 
developed and not viable. 

ANATOMICAL CHANGES IN THE TUBE. 

Mucous Membrane. In the tubal mucosa decidual changes 
are always to be found (Webster). This view is not universally 
accepted. Webster has never failed to demonstrate a decidua in 
the tube, but finds great variation in the location and extent of the 
development. The early specimens more clearly show this so-called 
genetic reaction than do the advanced cases. The decidua may be 
confined to a narrow ring about the tube. It is, therefore, not 
strange that conflicting statements are made concerning the presence 
of a decidua in the tube. 

It is often necessary to make sections from various portions of 
the tube. 

As in uterine pregnancy, so in the tube we find a decidua vera, 
reflexa, and serotina. The decidua vera is composed of a spongy 
and compact layer, as in uterine pregnancy. In the compacta the 
decidual cells are closely packed together, while in the spongy 
layer they are separated by gland-like spaces formed by mucous 
folds. In later months the distinction between the compact and 
spongy layers is lost. In the earlier stages the surface epithelium 
remains intact, but as time goes on the cilia are lost, the cells 
become flattened, and, finally, wholly disappear. As in the endo- 
metrium, the decidual cells are derived from the connective tissue 
of the mucosa. They are essentially greatly enlarged connective- 
tissue cells, and show great variation in size and form. In far- 
advanced cases these cells become elongated into a fibrous structure, 
and loose their decidual character. 



158 



SPECIAL DIAGNOSIS 



The decidua serotina, that portion of the decidua known as the 
placental site, is relatively larger than is the serotina of the preg- 
nant uterus. 



Fig. 48 




Hsematoma of the left broad ligament lying close to the uterus. 



Fig. 49 




Hsematoma of the left broad ligament and extending in front of the cervix to the right 

side of the uterus. 



The decidua reflexa may or may not be present. Some authorities 
disclaim its existence. As stated by Webster, the tube lumen may 



THE DIAGNOSIS OF ECTOPIC PREGNANCY 



159 



be so small that the ovum pressifig upon the wall of the tube makes 
the formation of a decidua reflexa impossible. On the other hand, 
the tube lumen may be exceptionally large, in which case a com- 



FiG. 50 




Hsematoma of both broad ligaments extending in front of the uterus. 



Fig. 51 




Hsematoma of both broad ligaments connected behind the uterus. 



plete reflexa may be formed. As the ovum develops the reflexa 
becomes thin and early disappears. 



1(J0 SPECIAL DIAGNOSIS 

Beyond the attachment of the ovum the tubal mucosa may not 
suffer change. Not infrequently decidual changes are recognized 
throughout the entire mucosa of the tube. As the ovum enlarges 
and fills the tube the surface epithelium is compressed and wholly 
disappears; so, also, with the decidua. 

The muscular wall of the tube varies in thickness in different 
sections and in the various stages of pregnancy. In the early 
months the musculature thickens through hypertrophy. In the 
later months pressure and stretching of the musculature may cause 
all traces of muscle fibres to wholly disappear. 

The peritoneal covering of the tube is stretched by the growing 
ovum. Inflammatory adhesions may form about the tube. 

Regarding the fetal membranes, there is little that differs from 
the membranes of normal uterine gestation. 

THE CLINICAL DIAGNOSIS OF ECTOPIC PREGNANCY. 

The clinical diagnosis of ectopic pregnancy is made, first, by 
establishing the fact of pregnancy, and, second, by locating the 
gestation sac. The subjective signs are of value in establishing 
the fact of pregnancy, but the location of the gestation sac can 
only be determined by a physical examination. 

Subjective Signs. The subjective signs may not differ mate- 
rially from those of uterine pregnancy of a similar age. In the 
early weeks of an ectopic gestation the patient is seldom aware 
of any unusual complications, while in the later months the symp- 
toms seldom conform to those of normal pregnancy, and give 
rise to feelings of apprehension on the part of the patient. Not 
so with the physical signs; these are to be differentiated from the 
normal from the earliest time. 

1. Cessation of menstruation occurs in about one-half of the cases. 
The hemorrhage when present comes from the endometrium. 

2. Morning sickness occurs at about the same time and to about 
the same extent as in uterine pregnancy. 

3. Nervous phenomena, such as ringing in the ears and despond- 
ency, are likely to be exaggerated above that of normal uterine 
gestation. 

4. Periodic colicky pains are unlike anything that should occur 
in normal uterine pregnancy. It is this incident that commonly 



THE DIAGNOSIS OF ECTOPIC PREGNANCY 161 

first attracts the patient's attention to her condition. These pains 
are said to be due to the contractions of the uterus and pregnant 
tube. In character they are intermittent and cramping, and are 
located in the region of the uterus and affected tube. During these 
pains rupture of the gestation sac may occur. 

Objective Signs. The objective signs differ essentially from 
those of uterine gestation. 

1. The mammary glands do not often show the marked changes 
accompanying uterine pregnancy. The areola is poorly marked 
and the secretion of colostrum is scant. 

2. Discoloration of the vulva and vagina, softening of the vaginal 
portion of the cervix, and compressibility of the lower uterine segment 
may all be present, but seldom to the degree found in uterine 
gestation. 

3. Active fetal movements may be recognized earlier and with 
greater ease than in uterine pregnancy, provided the foetus lies in 
close proximity to the abdominal wall. Later on the movements 
may be readily seen through the parietes. 

4. Intermittent uterine contractions are often present, though not 
to the degree found in uterine pregnancy. 

5. Direct palpation of the fetal parts may be very difficult and 
obscure, or very easy, depending upon the relation of the foetus to 
the abdominal wall. 

6. Auscultation, a. Fetal heart tones are heard, with varying 
degrees of distinctness, depending upon the development of the 
foetus, its relation to the abdominal wall, and upon the thickness 
of the latter. 

h. The fetal souffle is rarely heard, and only in the latter half of 
pregnancy. 

c. The placental souffle is rarely heard after the third month, 
and only on the side occupied by the gestation sac. 

7. The rate of growth, form, position, and consistency of the uterus 
vary considerably from that of uterine gestation. While the uterus 
almost always enlarges, it never attains a greater size than that 
of a four months' pregnant uterus, and does not enlarge regularly 
and progressively as does the gravid uterus. The nearer the ges- 
tation sac is to the uterus the larger the uterus develops. Cases 
are recorded in which the uterus did not develop, but these are 
exceedingly rare. 

11 



162 SPECIAL DIAGNOSIS 

The general contour of the uterus differs somewhat from that of 
the normal pregnant uterus. It retains much the same form as does 
the non-pregnant uterus. The transverse diameter is proportion- 
ately less, and there is no shortening of the cervix in advanced cases. 

The uterus seldom lies in the median line, but is crowded to one 
side by the gravid tube. 

In consistency the uterus changes, but not to the degree found 
in uterine gestation. 

8. The discharge of the uterine decidua is an event peculiar to 
ectopic pregnancy. Part or all of the uterine decidua may be 
expelled at any time during the course of an ectopic pregnancy. 
As a rule, the decidua is expelled piecemeal, rarely in its entirety. 
Much blood may accompany the discharged decidua and completely 
mask the accompanying fragments. Where ectopic pregnancy is 
suspected the escaped blood should be carefully preserved by the 
nurse for the inspection of the physician. 

Histologically, the uterine decidua of ectopic pregnancy does not 
differ essentially from that of uterine gestation, the distinguishing 
feature being the absence of fetal structures. 

Spurious Labor. At full term pains not unlike those of labor 
come on and constitute what is known as spurious labor. These 
pains may occur weeks before the end of full term, and, on the 
other hand, may altogether fail or be delayed one or more months 
beyond full term. The pains commonly continue a number of 
hours, as in normal labor, but have been known to persist for a 
week and longer. They vary in intensity and location; often they 
are severe and located in the side of the pelvis. A bloody discharge 
appears shortly after the onset of the pain, and with it there is 
usually a discharge of decidual membrane. The amount of blood 
lost may be alarming. 

Following spurious labor the foetus always dies, the liquor amnii 
becomes absorbed, the gestation sac contracts, and the foetus under- 
goes changes previously referred to, namely, mummification, litho- 
psedion, gangrene, and adipocere formations. 

9. "Intraperitoneal Hemorrhage. It may be stated at the outset 
that its signs and symptoms consist, speaking generally, of the signs 
and symptoms of an acute and sudden abdominal lesion "plus those 
of severe internal or concealed hemorrhage, and that whenever 
these are present in a female patient during the childbearing age, 



THE DIAGNOSIS OF ECTOPIC PREGNANCY 163 

the probability of their being due to a disturbed ectopic gestation 
should be vividly present to the physician's rnind. The first symp- 
tom is the occurrence of a sudden and severe pain in the abdomen, 
accompanied very often with vomiting. The patient almost imme- 
diately expresses herself as feeling extremely faint and ill. She is 
quite conscious, and remains so. The abdomen is often more or 
less distended and rigid, and it becomes excessively tender. There 
is soon noticed, along with the usual signs of collapse, a gradually 
increasing pallor of the surface. The pulse increases in frequency, 
without, at first, any corresponding rise in temperature, and becomes 
weaker and more compressible. Presently it is only now and then 
that it is perceptible, and finally it cannot be felt at all. The 
patient complains of feeling more and more faint; her pain perhaps 
abates; she becomes restless, sometimes vomits, often sighs deeply, 
yawns and exhibits other signs of weariness, and, if left untreated, 
gradually sinks, maintaining a perfectly clear intellect to the last. 

''Such is a picture, imperfect, as all attempts to describe such a 
condition in words must be, of the clinical aspect of a patient with 
diffuse intra-abdominal hemorrhage. Now and then the bleeding 
becomes spontaneously arrested, the patient rallies, and, if no fresh 
outburst occurs, the blood becomes gradually absorbed and the 
patient recovers. But the condition is one in which no such for- 
tunate result can be counted upon, and in which the tendency is 
not to recovery, but to death, and to very speedy death, for the 
majority of cases end fatally within forty-eight hours, and many 
within a much shorter time. In the case of the wife of a medical 
friend of my own, death occurred within three hours from the 
beginning of the attack. 

"If I were asked upon what points I should principally rely in 
diagnosing this condition, I should be disposed, in the light of my 
own experience, to enumerate the following, viz.: 

" (a) The fact that at the moment of the attack the patient was 
in her usual health. This circumstance would render it highly 
improbable that the symptoms were due to gastric or intestinal 
perforation or to rupture of an internal abscess or suppurating 
cyst. 

" (h) The gradually increasing pallor of the patient and the 
gradually rising pulse rate (without corresponding rise of tempera- 
ture), both being indicative of internal hemorrhage. 



164 SPECIAL DIAGNOSIS 

" (c) The extreme tenderness of the abdomen. To this symptom 
I have learned to attach a very special value. It often misleads 
the medical attendant into supposing that there is acute general 
peritonitis. It cannot, therefore, be too strongly insisted upon 
that marked, and even excessive, abdominal tenderness does not 
necessarily indicate an inflammatory condition. It is met with, for 
instance, in ovarian tumors when, as the result of rotation of the 
pedicle, they have become the seat of hemorrhages, intracystic and 
intramural. It is quite true that peritonitis is a not infrequent later 
result of this accident, but this marked tenderness may be observed 
when on opening the abdomen there is no visible sign of inflam- 
mation. 

" {d) If a menstrual period has been missed or is overdue the 
diagnosis of the case is greatly iacilitated; but it does not follow 
that because menstruation has been regular rupture of an ectopic 
gestation may be excluded. For some of the most appallingly 
sudden cases of rupture occur (as I hope to point out later) at a 
very early stage of the pregnancy, even, it may be, before a single 
period has been missed. Hence arrested menstruation is not 
essential to the diagnosis, though when present it is a valuable help 
to it. If in addition to the arrested or delayed menstruation there 
is morning sickness, the diagnosis is even further facilitated. But, 
after all, these signs of early pregnancy do not prove very much. 
They do not even prove that the pregnancy, if present, is ectopic, 
or that, whether it is or not, it has anything to do with causing the 
present illness. All that can be said is that when symptoms are 
present that suggest the possibility of a ruptured ectopic gestation 
these signs of pregnancy serve to confirm the suspicion. 

''These are, so far as I have been able to observe, the main helps 
to a correct diagnosis. 

"There still remains to be considered one or two other points of 
diagnosis of less importance than those just indicated. 

"It is frequently stated in text-books that when there is intra- 
abdominal hemorrhage there will be the usual signs of the presence 
of free fluid in the peritoneal cavity. In a case of very extensive 
effusion, and in a patient without much fat in the abdominal wall, 
it may be possible to obtain evidence of fluctuation and of dulness 
in the flanks, shifting on change of posture, but such evidence is not 
usually forthcoming. 



..»^ 



PLATE XXIL 






-;, -Vfil&Fic^^Sfe -.. 




V- 



Tubal Pregnancy. 

The ■wall of the tube is thickened. The villi are vascular anid 
near the centre of the lumen. Entangled in the meshes of the villi 
is an irregular blood clot containing numerous syncytial cells— this 
represents the fetal remains. 



THE DIAGNOSIS OF ECTOPIC PREGNANCY I65 

"Lastly, a word must be said as to the evidence obtainable by 
vaginal examination. Here, again, the signs are not very definite. 
There is no distinct circumscribed swelling to be felt, as in the case 
of encysted effusions (pelvic hsematocele). All that can be made 
out is, in the words of my friend Mr. John W. Taylor, ^a full and 
boggy condition of the pouch of Douglas, suggestive,' to the expe- 
rienced finger, ^of the presence of fluid or semiclotted blood within 
the pelvis, but,' as he goes on to say, 'the symptoms denoting that 
a lethal hemorrhage is actually taking place are of chief importance.' 

''There is very often a slight hemorrhage going on from the 
vagina, generally regarded by the patient either as due to the appear- 
ance of a delayed menstrual period, or, if she believes herself to be 
pregnant, as indicating the probability of a miscarriage. 

"Owing to the gradual subsidence of the pain, and the patient's 
freedom, as a rule, from anything like alarm about herself, the 
extreme gravity of the condition may easily be overlooked. In 
fact, as Mr. Taylor has pointed out, it is more frequent to find that 
the medical attendant has failed to appreciate the danger than that 
he has made an incorrect diagnosis." (Cullingworth.) 

10. Bimanual Examination. An anaesthetic will be found of 
immense advantage in making a bimanual examination. Great 
variations are observed in the local findings of ectopic pregnancy. 
Vessels are felt to pulsate in the vaginal vault, particularly on the 
side of the gestation sac. The vagina may be displaced and mis- 
shaped by the gestation sac and accumulated blood above. The 
vaginal walls are made to bulge at the sides and behind the uterus, 
and the vagina may be pushed far to one side. 

The uterus is almost invariably displaced by the tumor mass. 
The most common displacement is forward and upward, because of 
the frequency with which the blood collects in the pouch of Douglas. 
The uterus is elongated, but is never so broad as in uterine gestation 
of a similar period of development. Its consistency is firmer than 
in uterine pregnancy, the lower uterine segment is not well marked, 
and the cervix is not shortened. 

The pregnant tube is not unlike the inflammatory swellings of 
the tube. Without other evidences of pregnancy it would be impos- 
sible to say, with assurance, that the tube is pregnant and not dis- 
tended with blood, pus, or serum. As in sactosalpinx, the pregnant 
tube commonlv lies low at the side of or behind the uterus. 



166 SPECIAL DIAGNOSIS 

In interstitial pregnancy the gestation sac forms with the uterus 
a single mass, distinguished by a more elastic consistency as con- 
trasted with the firmer uterine tissue. 

11. Exploratory vaginal incision has been practised by Grandin 
and Spinelli as a last resort in the making of the diagnosis. Because 
of the inadvisability of operating on such cases through the vagina 
the better procedure would be to make 

12. An exploratory abdominal incision through which any operative 
procedure may be carried out. 

DIFFERENTIAL DIAGNOSIS OF ECTOPIC PREGNANCY. 

Pregnancy in a Retroverted Uterus. Since the gestation sac 
of an ectopic pregnancy frequently lies behind the uterus, and since 
in the early months the size, form, and consistency of the uterus 
of an ectopic pregnancy do not differ widely from that of intra- 
uterine pregnancy, confusion is likely to arise. Here an anaesthetic 
examination is of the greatest value. Under anaesthesia the uterus 
should be located and clearly outlined apart from any mass outside. 
In an ectopic pregnancy lying in the retrouterine space the uterus 
lies well forward, and by its form and consistency can usually be 
outlined apart from the gestation sac. The anatomical distinctions 
between the pregnant uterus and the uterus of an ectopic pregnancy 
are to be borne in mind. In uterine pregnancy the uterus is more 
elastic and soft, the lower uterine segment is clearly defined, and 
the transverse diameter is relatively increased. The possibility 
of a combined uterine and extrauterine gestation is to be borne 
in mind. 

Uterine pregnancy complicated with a tubal or ovarian swell- 
ing may easily be confused with ectopic pregnancy. The difficulties 
are increased when the uterus is enlarged through inflammation 
(chronic metritis). Such a uterus when gravid will not have the 
usual elasticity and softness of a normal pregnant uterus. On the 
other hand, the abdominal wall and uterine musculature may be so 
thin as to give the impression that the foetus lies outside the uterus. 
In the first trimester the physical examination of the uterus alone 
can only serve to suggest the possibility of pregnancy. When from - 
the size, position, consistency, and contour of the uterus pregnancy 
is suspected, the next step is to determine whether the adnexse are 



THE DIAGNOSIS OF ECTOPIC PREGNANCY 167 

enlarged from pregnancy, infection, or a new formation. The his- 
tory must be carefully considered, with special reference on the one 
hand to pregnancy and on the other to infection. The pregnant 
tube is usually of softer consistency and less tender than are inflam- 
matory swellings. More confusing still is the occasional occurrence 
of a tubal pregnancy implanted upon an inflammatory swelling of 
the tube. Here and indeed in all cases the history will be of the 
greatest value in making the differential diagnosis. The unilateral 
involvement of the tube is evidence in favor of tubal pregnancy, 
though bilateral tubal pregnancy is possible and unilateral involve- 
ment of the tube and ovary is common. A pregnant tube is not so 
likely to be fixed by adhesions as is a salpingitic swelling, and ten- 
derness is not so great. 

As a last resort, when a diagnosis is imperative, a sound may be 
passed into the uterus, or if there is evidence to support the belief 
that an abortion has occurred, the uterus may be curetted and a 
microscopic examination made of the scrapings. If decidua and 
fetal tissue are found the pregnancy must have been intra- 
uterine. 

If no decidua is found we are not to conclude that tubal preg- 
nancy cannot possibly be present, because it is possible that the 
decidua was previously expelled. This fact was illustrated by a 
case reported by Tanneus. 

Pelvic Exudate, Especially When following upon an Abortion. 
A period of amenorrhoea may be interrupted by uterine hemorrhage. 
No fetal structures may have been recognized in the escaped 
blood. From such a history the examining physician is unable to 
decide whether it was a uterine abortion or a ruptured tubal preg- 
nancy. If not examined until some time has elapsed, and there is 
found a mass in the pelvis, the question will arise as to whether 
there exists an inflammatory exudate or the gestation sac and the 
escaped blood of a ruptured ectopic pregnancy. If an inflammatory 
exudate, the history should point to a pelvic infection following the 
abortion, to a rise of temperature, and to pain in the pelvis. The 
mass should be firmly fixed and tender. In ectopic pregnancy 
there is less tenderness and pain, and the general symptoms of 
sepsis are not present unless the mass has become infected. A 
very good general rule to be remembered is that in a pelvic abscess 
the fever and high pulse rate precede the development of the pelvic 



168 SPECIAL BIAGNOSIS 

exudate, while in ectopic pregnancy there is no fever or rise of pulse 
rate before the development of the tumor. Furthermore, with the 
development of the inflammatory exudate the general symptoms of 
infection increase, while with the sudden appearance of an escaped 
mass following upon the rupture of a gravid tube the temperature 
is likely to become subnormal. 

Finally, an exploratory puncture or incision through the vaginal 
wall will determine the true nature of the swelling. If a pelvic 
abscess develops it may not be possible to determine whether it 
was derived from an inflammatory exudate or from a secondary 
infection of an ectopic pregnancy. In the removal of the pus, fetal 
tissue may or may not be discovered either by the naked eye or by 
the microscope. 

Pregnancy in a bicomate uterus may closely resemble an ectopic 
pregnancy. The diagnosis may be cleared up by the discovery of 
a septum in the vagina or cervix. It is seldom possible to palpate 
the round ligament, but if found to be attached to the uterus external 
to the gestation sac the pregnancy is either interstitial or in a horn; 
if the round ligament lies internal to the gestation sac a tubal preg- 
nancy is positively present. 

Pregnancy in a rudimentary horn cannot be distinguished from 
tubal pregnancy before opening the abdominal cavity. It is then 
recognized by finding the insertion of the round ligament external 
to the gestation sac. 

Ovarian tumors may be difficult to distinguish from an ectopic 
pregnancy. In ovarian tumors the breasts may enlarge and secrete 
colostrum, and there may be morning sickness and amenorrhoea. 
With the aid of an ansesthetic a bimanual examination should deter- 
mine the diagnosis. As a rule, the uterus can be clearly outlined 
distinct from the ovarian tumor, and is found not to differ from the 
normal non-gravid uterus. 

Rupture of an ovarian cyst may suggest a possible rupture of 
an ectopic pregnancy. The absence of a history of pregnancy, the 
presence of a long-standing tumor, and the absence of changes in 
the uterus suggestive of pregnancy, including a decidua, should 
suffice for the making of a diagnosis. 

Torsion of the pedicle of an ovarian cyst may give rise to pain 
and symptoms of internal hemorrhage not unlike those of a rup- 
tured ectopic pregnancy. A consideration of the points referred to 



THE DIAGNOSIS OF ECTOPJC PREGNANCY 169 

in the above paragraph on rupture of an ovarian cyst should serve 
in excluding rupture of an ectopic pregnancy. 

An ovarian tumor complicating pregnancy is at times confusing in 
the diagnosis. The shape, size, and consistency of the uterus will 
usually serve in determining the presence of a uterine pregnancy. 
The great improbability of a tubal pregnancy complicating a uterine 
pregnancy, together with the usual signs of an ovarian cyst, will 
usually clear up the diagnosis. If the cyst is large it will be observed 
that there is an absence of ballottement, of fetal heart tones, and 
of fetal movements in what is suspected of being a gestation sac. 

Fibromyoma of the uterus can scarcely be mistaken for ectopic 
pregnancy. There is an absence of a history of pregnancy. The 
uterus shows none of the changes characteristic of pregnancy. The 
tumor is of long standing, which, together with its firm consistency 
and close relation of the uterus to the tumor mass, should leave 
little doubt as to the diagnosis. An exploratory curettage of the 
uterus will fail to find a decidua. 

Malignant disease of the pelvis by its irregular outline may 
suggest an ectopic pregnancy, and the more so when occurring in 
the "dodging period." The absence of the signs of pregnancy and 
the presence of general signs of malignancy should exclude the 
possibility of ectopic pregnancy. 

Pelvic hsematoma and hsematocele not due to ectopic pregnancy 
are exceedingly rare. Causes other than ectopic pregnancy resulting 
in the formation of a hsematoma or hsematocele are obstructions to 
the outflow of the menstrual blood, rupture of varicose veins in 
the broad ligaments, rupture of an ovarian cyst and of the uterus. 
In determining the origin of the blood mass the first and most 
important step is the consideration of pregnancy. In long-standing 
cases of hsematoma and haematocele following upon the rupture of 
an ectopic pregnancy it may be impossible to find any evidence of 
pregnancy either in the tube or in the uterus. (See Plate XXIV.) 

Acute Abdominal Affections. Of all acute abdominal affections 
in woman ruptured ectopic pregnancy is most important from a 
gynecological point of view. There are a number of acute affec- 
tions of the abdominal organs which have very similar clinical 
manifestations, and it is imperative that a diagnosis be made at 
the earliest possible moment in order that proper surgical inter- 
ference may be instituted. 



170 SPECIAL DIAGNOSIS 

The importance of differentiating these various lesions will 
justify a thorough consideration at this point. The following are 
the acute abdominal affections which may simulate ectopic preg- 
nancy in their clinical manifestations: 

1. Appendicitis. 

2. Intestinal colic. 

3. Renal colic. 

4. Hepatic colic. 

5. Internal hernia. 

6. Acute pancreatitis. 

7. Movable kidney. 

8. Rupture of a gastric or duodenal ulcer. 

In differentiating these conditions we must first consider the 
previous history, then the present complaints, and finally proceed 
to a physical examination. 

1. Appendicitis in its onset and in its further course may very 
closely simulate a ruptured tubal pregnancy. In the first place 
we have in appendicitis none of the general and local signs of preg- 
nancy. There is often a history of similar attacks, with intervals 
of complete or partial freedom from pain and intestinal disorders. 
The distress is almost always confined to the right side, while in 
ectopic pregnancy it is often referred to the median line or left side. 

In both of these conditions the pain appears suddenly, and may 
be intense; in ectopic pregnancy it may be momentary, while in 
appendicitis it persists throughout the attack. It is said that the 
pain of appendicitis comes more often in the early morning hours, 
while the pregnant tube ruptures at any time from physical exertion. 
The sudden pallor and collapse frequently following immediately 
upon the rupture of a tubal pregnancy never occur in appendicitis. 
It is at this time that a most suggestive sign appears — i. e., uterine 
hemorrhage accompanied by a discharge of decidual membrane. 
In such an event there can be no further consideration of appen- 
dicitis. Much dependence is placed upon the finding of an enlarged 
soft uterus and an irregular mass attached to it at the side or laying 
behind the uterus. Where doubt exists the uterus may be explored 
with a curette and the scrapings examined for decidual tissue. 

We have seen that in intraperitoneal hemorrhages from rupture 
of the gestation sac the abdomen may be distended, firm, and 
tender, and that this may be associated with nausea and vomiting. 



THE DIAGNOSIS OF ECTOPIC PREGNANCY 171 

Here the diagnosis must rely almost wholly upon the previous 
history. 

2. Intestinal colic begins with griping abdominal pains, vomiting, 
and diarrhoea. This may lead on to collapse. Often a cause for 
the intestinal colic can be elicited. Lead colic is rarely seen in 
women. The blue line on the gums, constipation, and colicky 
pains about the umbilicus found in a patient working with lead 
will fix the diagnosis of lead colic. 

3. Renal colic should not be difficult to diagnose from rupture 
of an ectopic pregnancy. When occurring during the course of a 
uterine pregnancy renal colic may excite suspicion of a ruptured 
tubal pregnancy. In renal colic the pain is severe and increasing, 
it is sharp and radiates to the groin and thigh. Vomiting, sudden 
rise of temperature, cold sweats, and collapse are frequent accom- 
paniments. Watching the urine closely, blood will be seen to appear, 
though the microscope may be required to detect it. All urine 
voided should be searched for the stone. These events, in the 
absence of an extrauterine pelvic mass, will serve for a diagnosis. 
A history of previous attacks will be highly suggestive. It is possible 
that the presence and location of the stone can be determined by 
means of the a;-ray. 

4. Hepatic colic frequently arises after the childbearing period. 
When associated with pregnancy the rupture of an ectopic preg- 
nancy would naturally be suggested. Flatulent dyspepsia has 
usually been a more or less constant complaint. Pain is referred 
to the right hypochondrium, epigastrium, right shoulder, and 
back. Associated with this is epigastric tenderness, nausea, and 
vomiting. If the stone passes into the common bile-duct there will 
be jaundice, clay-colored stools, and bile in the urine. The gall- 
bladder may be distended and tender. If gallstones are passed 
by the bowel or seen by the o^-ray the diagnosis is established. 
There is little in such a history to suggest rupture of an ectopic 
gestation sac, and yet mistakes have been made. 

5. Internal hernia usually begins with pain, which may be severe 
or slight, and even absent. Vomiting is often the earliest sign, and 
this becomes stercoraceous. There is no gas or fecal matter passed 
by the bowel. In the urine indican is present in large quantities. 
None of the symptoms point to the pelvis, and a vaginal examination 
excludes the possibility of ectopic pregnancy. 



172 SPECIAL DIAGNOSIS 

6. Acute pancreatitis is frequently regarded as an aggravated 
form of indigestion until the patient is seized with severe pain in 
the epigastrium, repeated vomiting, and collapse. The epigastrium 
is tender on pressure, though there is no distention. Collapse may 
follow upon persistent vomiting. There is little possibility of mis- 
taking such a condition for ectopic pregnancy, though the abdominal 
pain, vomiting, and collapse occurring in a woman of the child- 
bearing period should first of all suggest an abnormal condition 
of pregnancy and call for an immediate physical examination. 

7. Movable kidney is seldom associated with such intense pain 
and shock as to become a serious acute abdominal affection. The 
pain is usually referred to the right hypochondrium, and may be 
associated with vomiting and shock. Palpating a firm, tender, 
kidney-shaped tumor in the right lumbar or iliac space and the 
ability to readily force this tumor beneath the right costal arch will 
determine the diagnosis. A history of previous lesser pains and 
a dragging sensation coming on in the right hypochondrium 
shortly after rising and relief upon lying down will suggest the 
diagnosis. 

8. Rupture of a gastric or duodenal ulcer will almost always occur 
after a meal and upon exertion. There is a previous history of 
anaemia and indigestion in nearly all cases. The vomiting of blood 
and gastric pains are frequent events. The history and a pelvic 
examination will exclude ectopic pregnancy. 



CHAPTEE XX. 

DIAGNOSIS OF HYDATIFORM MOLE. 
Synonyms. 
History. 
Etiology. 

Microscopic Diagnosis. 
Malignant Degeneration. 
Clinical Diagnosis. 

Synonjrms. Hydatiform degeneration of the chorion; uterine 
hydatids; vesicular mole; myxoma chorii; blasenmole; cystic mole; 
hydatid mole; dropsy of the villi. 

History. In a valued contribution by R. Kossman, Berlin, we 
are given in the German text translations of the original manu- 
scripts on hydatiform mole from the time of iEtius von Ameda, in 
the early part of the sixteenth century, to the time of Virchow, 
in the latter part of the nineteenth century. 

Hippocrates was evidently acquainted with the condition as a 
cause of abortion. He states that when the '^cotyledons" fill with 
mucus the menses become scanty; and if the woman becomes preg- 
nant, abortion occurs after the embryo has attained considerable 
size. 

It is interesting to note that as late as the early part of the nine- 
teenth century it was believed that conception was not essential to 
the development of a hydatiform mole. Dating from the writing 
of Velpeau, the lesion has been universally recognized as a degen- 
eration of the chorionic villi. Since then it has been a question as 
to the cause of the degeneration of the chorionic villi and the char- 
acter of the degeneration. Virchow may be credited with having 
advanced the modern theory as to the pathological nature of hydati- 
form mole, though his views are not universally accepted. (See 
later.) 

ETIOLOGY OF HYDATIFORM MOLE. 

Nothing definite is known of the immediate and remote causes of 
hydatiform mole. The age at which it commonly occurs is said 
to be near the end of the childbearing period. According to Bowin 

(173) 



174 



SPECIAL DIAGNOSIS 



25 per cent, are found between the ages of forty and forty-six years. 
Schroeder reported one occurring at seventeen years of age. In 
210 cases tabulated by the author it is seen that the average age 
is twenty-seven years; that the extreme ages are thirteen and fifty- 
eight years, and that the greatest number occur between the ages 
of twenty and thirty years. As to the frequency of recurrence, it is 
not unusual for a woman to give birth to a second mole some months 
or years after the expulsion of the first. In the second case here 
reported there was an interval of about twenty months between the 



Fig. 52 




Section of the uterus with the mole in situ. 



expulsion of the first and second mole. Fritsch records a case in 
which there were four moles successively developed. Majer records 
.eleven moles and a single child born of one woman. 

It is stated that syphilis, ansemia, heart and kidney lesions, and 
tuberculosis are general predisposing factors in the production of 
hydatiform mole, but proof of this is wanting. The question as to 
whether the lesion is of maternal or of fetal origin is not fully 
settled. In favor of the view of the maternal origin may be men- 
tioned the recurrence of the mole in the same individual and by 
different husbands; the common occurrence late in life; the partial 



DIAGNOSIS OF HYDATIFORM MOLE I75 

vesicular degeneration of the chorion in the presence of a perfectly 
healthy foetus; the common occurrence of cystic degeneration of the 
ovaries associated with hydatiform mole; and, lastly, that endo- 
metritis and nephritis commonly precede the development of hydati- 
form mole. In favor of the fetal origin is the fact that in twin 
pregnancy one mole alone may be involved in the cystic degenera- 
tion of the chorionic villi. If, as has been stated, death of the foetus 
is a cause for vesicular degeneration of the chorion, how are we to 
account for the rarity of the lesion in cases of missed labor and 
abortion, where the foetus has remained dead for weeks and months 
in the uterus? The fact that in partial vesicular degeneration of 
the villi the foetus may remain perfectly healthy forces us to the 
more probable conclusion that extensive vesicular degeneration 
of the chorion results in the death of the foetus. Contrary to the 
evidence advanced in support of the theory of maternal origin is 
the occurrence of many moles prior to the formation of the placenta, 
at the time when there is not an intimate anatomical relation of the 
mole to the uterine wall. Marchand holds that hydatiform mole 
occurring early in fetal life can be ascribed to a primary change 
in the ovum. He does not deny the possibility of other causes 
operating to produce partial degeneration of the chorion, and 
adrnits as highly probable that malnutrition has much to do with 
the development of the mole. 

Van der Hoeven examined ten hydatiform moles, of which nine 
were in the third, fourth, and fifth months of fetal development; 
the tenth was in the first month. The last showed no vesicular 
degeneration of the reflexal placenta. Van der Hoeven reasoned 
that the ovum was healthy when it reached the uterus, and that it 
is possible that the disease was primary in the uterine wall, though 
not probable. In support of the theory of uterine origin he found 
degenerative changes in the endometrium. Virchow was the first 
to suggest the possible causal relation of endometritis to hydatiform 
mole. From the great frequency of endometritis complicating 
pregnancy as compared to the relative infrequency of hydatiform 
mole, it is not likely that any direct relationship between the two 
lesions can be established. It would be difficult to determine 
whether the changes in the endometrium are primary or secondary 
to the development of the mole. Again, the histological changes 
in the endometrium associated with hydatiform mole are by no 



176 



SPECIAL DIAGNOSIS 



means constant. It has been suggested by Baumgart, Marchand, 
Kaltenbach, Krentzmann, Runge, Fraenkel, and others that the 
tendency to cystic degeneration of the ovum may be referred to 
cystic degeneration of the ovaries. Each of the above-named 
authors has reported a case of hydatiform mole comphcated by 
cysts of the ovary, and in a single case there was also a cystic kidney. 
In my second case both ovaries were cystic, each about the size 
of a man's fist. In 210 recorded cases tabulated by the author in 
only 8 were cystic ovaries recorded. The number of abdominal 



Fig. 53 




Section of the uterine musculature, decidua, and mole. X 4. 

incisions made in these cases is few — a fact which possibly accounts 
for the above statistics. On the other hand, cystic' degeneration of 
the ovaries is so commonly observed as compared with hydatiform 
mole that it is not likely that they stand in the relation of cause 
and effect. Fraenkel advances the theory that the distended follicles 
press upon the corpus luteum of pregnancy and so interfere with 
secretion as to bring about these changes in the fetal membrane. 
This theory is based upon the assertion made by Fraenkel that the 
corpus luteum is a secreting gland and that the secretions govern 



DIAGNOSIS OF HYDATIFOBM MOLE 177 

menstruation, together with the embedding and development of 
the ovum. 

Matwejew and Sykow reported in the Gynecological Society of 
Moscow a case of tubal pregnancy in which the placenta had under- 
gone cystic degeneration, and the ovary was likewise cystic. The 
patient was aged thirty-two years; she had had four normal labors 
and three abortions. The right tube contained the ovum, which 
ruptured about the eighth week of pregnancy. Symptoms of 
internal hemorrhage followed the rupture of the tube. Abdominal 
section revealed a large collection of blood in the pelvis, and a 
ruptured tube, within which was a hydatiform mole. The author 
stated that the cystic ovaries were undoubtedly the cause of the 
cystic degeneration of the placenta. 

MICROSCOPIC DIAGNOSIS OF HYDATIFORM MOLE. 

The Decidua Vera. The glands do not differ essentially from 
those of normal pregnancy. In size, number, and general outline 
there is nothing unusual. The secreting epithelium of the glands 
is partially lost; the remaining cells are cubical or flattened. In 
the gland lumen are many desquamated and degenerated epithelial 
cells and not rarely free blood and leukocytes. The decidual cells 
present no anomalies in structure; as in normal pregnancy they 
present a variety of forms, the greater number being polygonal 
or spindle-shaped. In the compacta they are more uniformly 
spindle-shaped, with elongated nuclei. Free blood, together with 
groups of leukocytes, is found between the decidual cells and the 
musculature. 

The Decidua Serotina. On the surface of the decidua serotina is 
a thin, fibrinous layer in which decidual cells are scattered. The 
decidual cells are round, polygonal, and spindle form, with large, 
round, granular nuclei. The glands are large, irregular in form, 
and the secreting epithelium flattened or cubical. Bloodvessels 
are intimately associated with the decidual cells, and free blood is 
found in the decidua and musculature. 

Chorionic Villi. It is observed that the intensity of the stain is 
subject to great variation, particularly in the connective-tissue 
stroma. The larger the villus the fainter is the stain; while in the 
largest villi the central portion of the stroma utterly fails to take a 

12 



178 



SPECIAL DIAGNOSIS 



stain, thereby showing complete degeneration and loss of tissue. 
At the periphery of the villus, where the stroma is seldom if ever 
wholly lost, there is a faint stain, showing but partial degeneration. 
This is best shown by the Van Gieson stain. Great variations in 
staining are also shown in the epithelial layer, the cells lying nearest 
the stroma taking the stain more faintly than those at the periphery. 
The non-degenerated connective tissue of the villus is of the 
embryonal type; the cells are elongated, having spindle-shaped 
nuclei. There is not the degree of development into fibrillse as 
described by Webster in the chorion of the fourth month, but it 
resembles in point of development the villus of four to six weeks' 
development. The first evidence of degeneration in the connective 
tissue is shown in the indistinct outline of the cell body, which 

Fig. 54 



' ,i>.^***MSf .vj/** 











/ 






*-*'**?»'»*9VS.«r-~'^'''^ 



Cystic degeneration of the villus, with an islet of syncytium within the degenerated stroma. 

becomes a granular substance beset with stellate cells containing a 
granular nucleus, and from which radiate fine fibrillar processes. 
Finally the formed elements disappear, and there is left an irregular 
space filled with clear serous fluid. At the periphery, in close 
touch with Langhans' layer, there always remains more or less con- 
nective tissue, arranged in concentric layers, which is more fibrillar 
than that of the centre of the stroma. In none of the villi is the 
stroma wholly degenerated. The degeneration of the stroma is in 
direct proportion to the size of the villi; in the smaller villi there 
is little if any degeneration. The process seems to be a granular 
degeneration or necrosis, with subsequent absorption, leaving 
spaces which fill with serum. I have not been able to demonstrate 
mucoid degeneration, as was first affirmed by Virchow. Storch 



DIAGNOSIS OF HYDATIFOBM MOLE 179 

took issue with Virchow on this point, and, after him, the lesion 
is spoken of as "cystoid degeneration of Storch.'' Other author- 
ities, while agreeing with Storch, disagree as to the manner by 
which this "cystic degeneration" is brought about. Merkle and 
Giese call it a secondary oedema due to an inhibited formation 
of the placenta. Koster and Rumler believe it to be an oedema 
of the stroma resulting from interference with the circulation 
through the pedicle of the vesicle. 

Krentzmann also takes issue with Virchow. He says: "Vesic- 
ular mole is the result of an irregular proliferation of the epithelial 
parts of the chorion, with hydropic swelling and consecutive necrosis, 
manifested especially in the larger vesicles. The superficial stratum 



/. 



Fig. 55 



« 






. p 







*«•' 



<**«-< 



Pmlffj' , 






Beginning degeneration of the stroma, with unusual proliferation of the syncytium. 

of the stroma — that which is near the living epithelium — remains 
unchanged, but the inner parts become liquefied." 

In addition to the above-named authorities may be mentioned 
Marchand, Fraenkel, and Neumann, who believe in the cystic 
degeneration theory as opposed to the myxomatous degeneration 
theory of Virchow. They speak of the proliferation of the epithelial 
elements as being coincident with the liquefaction of the stroma. 

Bloodvessels in the villi are difficult to demonstrate. Webster 
in describing the chorion of the sixth week of development says: 
"Most of the villi have capillaries. These consist simply of a tube 
of small, flat, endothelial cells around which the connective tissue 
is somewhat condensed, though to a different extent in various 



180 SPECIAL DIAGNOSIS 

places." No bloodvessels were seen in a large cystic villus; and 
when seen in the small, less degenerated villi they appear thicker 
walled than is described by Webster {vide supra). No calcareous 
deposits were seen in the villi. The most significant changes centre 
in the epithelial elements of the chorion. There is seen an active 
and very irregular proliferation of the epithelial cells, with a ten- 
dency to invade the uterine structures to a degree not seen in 
normal pregnancy. Before degenerative changes are noted in the 
stroma the epithelial layers proliferate to an unusual degree. This 
proliferation of epithelium is particularly marked at the tips of the 
villi. The larger the villi the greater the proliferation. This pro- 
liferation, while similar in character, is to a greater degree than is 
found in normal pregnancy of the same age, and may surpass that 
found at any time of pregnancy. 

In the syncytium and Langhans' layer of the small villi there is 
little change from the normal. As the villi enlarge through degen- 
erative changes in the stroma and proliferation of the epithelial 
elements there are seen in the periphery of the villi, particularly 
at the distal end, clumps and buds of protoplasmic bodies taking a 
deep stain and containing irregular groups of nuclei. Irregular 
vacuoles are seen in these protoplasmic bodies. The protoplasm is 
finely granular, and takes a fainter stain than do the nuclei. The 
buds and clumps of protoplasm take a deeper stain than do the 
remaining portions of the epithelium. Here and there in the larger 
villi irregular nests of syncytium are seen in the stroma of the 
villi. These, according to Van der Hoeven, are prima facie evi- 
dence of malignancy. A careful study of my specimens relative to 
this phase has led me to the conclusion that such is often, though 
not always, an accidental finding, due to tangential cutting of the 
villus, and not to an active invasion of the stroma by the epithelial 
elements. These changes in the syncytium and Langhans' layers 
are essentially hyperplasia and necrosis of the cell elements; the 
protoplasm increases in amount and the nuclei in size and number. 
The vacuoles are in number and size directly proportionate to the 
amount of epithelium, and are doubtless due to degenerative changes 
from malnutrition. Coagulation necrosis of the syncytium is more 
or less in evidence throughout the specimen. With the death of 
the foetus there is loss of the fetal blood supply to the villi. This 
does not necessarily result in necrosis of the villi, provided the 



DIAGNOSIS OF HYDATIFORM MOLE 



181 



maternal blood supply is sufficient to supply the needed nourish- 
ment; on the contrary, the villi may continue to grow. 

According to Marchand, the fetal blood is of minor importance 
in supplying nourishment to the villi. As evidence of this he has 
demonstrated necrosis of the stroma in the presence of a fetal blood 
supply and in the absence of a syncytial covering. His conclusion 
is that the syncytium exercises a governing influence over the 




5 % 






/ ' . * * 






Group of degenerated \'illi, showing proliferation of the syncytium. 

maternal blood supply to the stroma of the villi; when destroyed 
the stroma will undergo degenerative changes. Marchand asserts 
that a well-formed stroma is found only where the maternal circu- 
lation is adequate and the syncytium intact. 

It is found that in partial moles where the maternal circulation 
is less disturbed the necrosis of the stroma is correspondingly less. 
It would appear, then, that the remote cause of the necrosis of the 



182 SPECIAL DIAGNOSIS 

chorion lies in the failure on the part of the maternal circulation 
leading to degeneration of the connective tissue, and to a serous 
exudate which finally replaces the stroma of the villi. Peters 
believes the syncytium to be a sort of endothelial layer lining the 
intervillous spaces and exercising some important part in the func- 
tion of interchange between maternal and fetal circulation. Further- 
more, that it serves to protect maternal blood from direct contact 
with Langhans' layer, which probably has some coagulating or 
destructive influence on the maternal blood. 

With a disturbance of the maternal circulation the reciprocal 
relations between the maternal and fetal circulation are altered, 
and as a result, there is added to necrosis of the stroma a serous 
exudate, with the formation of cystic spaces filled with clear serum. 
The accumulated fluid in turn causes further necrosis of the stroma 
through compression ; complete degeneration of the connective-tissue 
fibres is seldom if ever seen. There is always a limited amount of 
fibres compressed in a concentric manner immediately beneath 
T>anghans' layer. In the larger villi there is also pressure necrosis 
of the epithelial covering, affecting both Langhans' layer and the 
syncytium. 

MALIGNANT DEGENERATION OF HYDATIFORM MOLE. 

The greatest interest in hydatiform moles centres in the fact of 
their liability to undergo malignant degeneration. Solowij and 
Korzysz-Kowski have shown that about 10 per cent, of hydatiform 
moles become malignant. On the other hand, it is generally recog- 
nized that fully 40 per cent, of the cases of syncytioma malignum 
arise from hydatiform mole. In collecting reported cases of hydati- 
form mole I have found a scarcity of case-reports of non-complicated 
hydatiform mole; that cases are seldom reported unless they have 
undergone malignant degeneration. For this reason it is impossible 
to arrive at any exact estimate of the frequency of hydatiform moles 
and of their malignant degeneration. Referring to the reported 
cases, which include all I am able to find in the literature, it 
appears that 16 per cent, of hydatiform moles become malignant. 
For the reason stated above it is probable that this percentage 
is far too high. 

From the very onset the difficulties involved in dealing with the 



DIAGNOSIS OF HYDATIFORM MOLE 183 

many mooted questions concerning the malignancy of hydatiform 
mole appear insurmountable. The intimate blending of fetal and 
maternal structures, together with the secondary processes of degen- 
eration, are so complicated and are so subject to variations that it 
is difficult and at times impossible to distinguish the benign from 
the malignant. Indeed, Van der Hoeven goes so far as to state 
that all hydatiform moles are malignant; that the proliferation 
of the epithelial elements of the chorion (syncytium, Langhans) 
assumes a malignant type in the invasion of the uterine musculature 
and connective-tissue stroma of the villi. He further reasons that 
if this tendency on the part of the epithelial elements to proliferate 
is not marked, or if the mole is expelled or removed before the 
epithelium invades the uterine tissue beneath the line of cleavage 
(within the compact layer of the decidua), there can be no recur- 
rence. If left behind in the uterine tissue, the epithelial elements 
continue to proliferate and to be carried to distant parts of the body 
by way of the blood stream, there forming metastatic malignant 
epithelial growths. 

Neumann studied 8 cases of hydatiform mole; 5 were not fol- 
lowed by malignant changes, 3 died of syncytioma malignum. In 
the 5 so-called benign moles the epithelium of the chorion pro- 
liferated to an unusual degree, but did not invade the connective 
tissue of the stroma, while in the 3 malignant moles the connective- 
tissue stroma was invaded by syncytial giant cells. Neumann 
arrived at the conclusion that the earliest evidence of malignancy 
lay in the invasion of the connective tissue stroma of the villi by 
the epithelial elements of the chorion. As suggested by Pierce, the 
"view of Neumann is not generally recognized, and with right, for 
cases of nephritis and lead poisoning have since been described 
where the same cells were found in the stroma of normal villi; 
hence their presence can have no pathological significance in 
hydatiform mole." 

It is evident from Ihe observations of Veit, Webster, Pick, and 
others that the invasion of the deep structures of the uterus, and 
even of structures beyond the uterus, by chorionic epithelium, is 
not evidence 'per se of malignancy; that, on the contrary, syncytial 
masses are found in the uterine musculature, and are deported to 
distant parts of the body by veins in normal pregnancy; that soon 
after the termination of pregnancy they disappear. The transition 



184 SPECIAL DIAGNOSIS 

between benign and malignant chorioepithelial elements is a gradual 
and imperceptible one, just as is true in the transition of all benign 
hyperplastic growths into the malignant types; and to differentiate 
them is manifestly impossible. There undoubtedly exists an inter- 
mediate stage between the benign and malignant. Berry Hart 
examined a hydatiform mole in which the epithelial changes were 
identical with those described in the malignant type; no recurrence 
followed the expulsion of the mole. Both the syncytium and 
Langhans' cells participate in the proliferative changes, but to a 
varying degree. There is, likewise, great variation in the rate of 
growth in the epithelial elments, the explanation not only lying 
inherent within the cell elements, but also in the degree of resistance 
offered by the uterine tissue. 

Two of the cases described by Kworostansky were in the second 
month of pregnancy — one a benign hydatiform mole, the other a 
syncytioma malignum. It is of the greatest interest to compare 
these two cases from an anatomical point of view. In the benign 
mole there was unusual proliferation of the syncytium and Lang- 
hans' layer, forming a loose connection with the decidua serotina; 
in the veins of the serotina both syncytial and Langhans' cells were 
found in limited numbers. The decidua vera was invaded to a 
lesser degree; no epithelial elements were found in the uterine 
musculature. In the placental site were evidences of endometritis, 
as demonstrated in scrapings removed six weeks after the expulsion 
of the mole. The case recovered without recurrence. The author 
states that the patient, aged twenty-four years, was anaemic, and 
that this impoverishment of the blood afforded insufficient nourish- 
ment to the villi, thereby exciting the chorionic epithelium to extend 
deeper into the uterine musculature in order to obtain greater 
nourishment. Sufficient nourishment not being provided by the 
stroma of the villi, necrosis follows. In the second case, which 
was malignant, there was also extreme ansemia. The epithelial 
elements behaved similarly to that of the first case, only to an 
exaggerated degree, apparently differing only in the degree of 
epithelial invasion of uterine structures. The syncytial cells in- 
vaded the intermuscular spaces and veins of the uterus as far as 
the parametrium. Atrophy and necrosis of the decidual and mus- 
cular elements followed ; bloodvessels were changed to blood lacunae. 
In comparing my specimen of benign hydatiform mole with one 



DIAGI^OSIS OF HYDATIFORM MOLE 186 

having undergone malignant changes, it was advisible to select for 
comparison not only one of similar age, but also one that had been 
removed together with the uterus, as was mine. In this way we 
avoid certain retrogressive changes and the disturbance of anatom- 
ical relations which would otherwise mislead. Two such cases 
have been reported — one by Boten and Vassmer, the other by 
Neumann. In both these cases the essential variations from my 
own case appear to lie in the more marked proliferation of the 
syncytium and Langhans' cells and in their extended invasion of 
the uterine veins and musculature. While it is not to be expected 
that a benign mole may be recognized from a malignant mole by 




Distal end of a chorionic villi, showing beginning degeneration of the stroma. 

the naked eye, yet it is worth while to observe that Pautz and 
others have found in malignant moles that the villi rarely attain 
large size, are firm, and have a long, slender pedicle, giving to the 
mole the appearance of soft-cooked rice. 

Ladinski, in a recent clinical review of deciduoma malignum, 
reported a case of hydatif orm mole followed by malignant degenera- 
tion. He collected thirty-three similar cases, and concluded that 
malignant degeneration occurred most frequently in cases where 
mole pregnancy terminated in the fourth month. It does not 
appear that the length of time a mole remains in utero has any influ- 
ence upon its disposition to become malignant. In twenty cases 
Ladinski finds the average time of appearance of syncytioma 
malignum is eight weeks after the mole has been expelled. 



186 SPECIAL DIAGNOSIS 

CLINICAL DIAGNOSIS OF HYDATIFORM MOLE. 

The rate of growth of the uterine tumor is the most constant 
and characteristic sign of hydatiform mole. With few exceptions, 
the size of the uterus is greater, even to double that of the normal 
pregnant uterus of a like period. At twelve weeks it has been 
found larger than the average pregnant uterus at full term. The 
growth is not usually symmetrical; in a number of cases the uterus 
is found to be proportionately broad. Furthermore, the rate of 
growth is not uniform. Near the time of expulsion the uterus fre- 
quently assumes a very rapid growth, soon to be followed by uterine 
pains and profuse hemorrhage. Within twenty-four hours the 
uterus may ascend two or three fingers' breadth. 

Hemorrhage is usually the first symptom to attract the attention 
of the patient. Preceding the hemorrhage is a period of amenor- 
rhoea extending over one, two, or three months — rarely longer. In 
a single case hemorrhage appeared in the third week of gestation, 
and again as late as the fifth month. The usual time of occurrence 
is in the second and third months. It is occasionally stated that 
the hemorrhage is more profuse at night. This was true in my 
first case, there being very little loss of blood during the day, and 
profuse bleeding at night. As a rule, the hemorrhage is at first 
slight, gradually increasing in amount and frequency, finally becom- 
ing continuous and in such quantities as to cause more or less 
anaemia. Hemorrhage is always to be feared at the time of the 
expulsion of the mole; this is particularly true when the mole is far 
advanced and when firmly adherent to the uterus. It has been 
known to recur within a week- in a case that did not prove to be 
malignant, but such an event is exceptional. Where malignant 
degeneration has followed the birth of a mole hemorrhage is known 
to have recurred nine days after the mole was expelled, and as 
late as four and one-half years. Consulting the statistics, it is seen 
that hemorrhage ushering in malignant changes first appears in 
the first and second months, with about the same frequency as in 
the fifth and sixth months following the expulsion of the mole. We 
may j or mutate the dictum that hemorrhage recurring weeks and 
months after the expulsion of a hydatiform mole is suggestive of 
malignancy, and demands immediate and thorough investigation 
into the cause. 



DIAGNOSIS OF HYDATIFORM MOLE 187 

Nausea and vomiting are present in a larger percentage of cases 
than is common to pregnancy. Severe and uncontrollable vomiting 
occurred eighteen times in the 210 collected cases. The explanation 
probably lies in the unusual distention of the uterus. 

Pain in the back and pelvis is complained of in nearly all cases, 
but does not usually develop until hemorrhage has persisted for 
some time. Not infrequently pain is absent until the hemorrhage 
is profuse and the cervix dilating. 

In extensive degeneration of the chorion the foetus dies early and 
is absorbed. We then have none of the physical evidences of a 
foetus. In partial degeneration of the chorion the development 
of the child may not be hindered, and there may be no clinical 
evidences of vesicular degeneration. 

The consistency of the uterus is a subject of some importance 
from a diagnostic point of view. Poten reported eleven cases of 
hydatiform mole, in three of which he observed irregular contrac- 
tions of the uterine wall. These contractions were localized over 
a limited area, and were transient, lasting but a few minutes and 
reappearing at variable intervals. To the examining finger they 
might easily be mistaken for intramural fibroids. Poten does not 
claim this is a reliable sign, but suggests that further investigation 
of the phenomenon be made. 

An early diagnosis of hydatiform mole is of importance because 
of the liability to malignant degeneration. While, as a rule, there 
will be the usual clinical signs of a mole some time before malig- 
nant changes develop, there is always the possibility of early 
malignant transformation, and it is not possible to detect these 
early malignant changes. 

Our only safeguard lies in the early recognition of the mole and 
in its immediate removal. 

Will the microscope supply an infallible means of making an 
early diagnosis of malignant degeneration of a mole? We do not 
accept the statement of Van der Hoeven and Neumann that epithe- 
lial invasion of the stroma of the villi is the earliest and at all times 
reliable evidence of malignancy. As has been stated, such findings 
are not uncommon in normal pregnancy. Marchand failed to find 
the stroma invaded in a malignant mole, and Ruge found such 
invasion in an undoubted benign mole. In my second case there 
was epithelial invasion of the stroma of the villi. Two years have 



188 SPECIAL DIAGNOSIS 

elapsed since the removal of the mole, and no signs of malignancy 
have developed. 

In a case reported by Poten the mole went on to the time of full- 
term pregnancy. Neumann's cells were found in the stroma of the 
villi. On the twenty-sixth day after the mole was expelled hemor- 
rhage recurred to a slight degree. The uterus was curetted, and a 
microscopic examination of the scrapings showed no evidence of 
malignant invasion; recovery followed. This case shows how 
difficult, and at times impossible, it is to determine the character 
of a hydatiform mole. In the light of our present knowledge we 
must always make a guarded diagnosis in the early stage; and at 



Fig. 58 






• ^ 








Giant syncytial cells showing vacuoles. 

no time can a diagnosis be made with absolute certainty from the 
expelled mole. The invaded decidua, and if possible the underly- 
ing musculature, w^ill alone afford evidences of malignant invasion 
prior to the development of metastasis. In the case reported by 
Schmidt a diagnosis of malignancy was first made from a micro- 
scopic examination of a metastatic growth which appeared in the 
vagina. The uterus was not removed, and recovery followed the 
removal of the vaginal growth. When hemorrhage recurs days or 
weeks after complete removal of the mole the uterus should be 
curetted and the scrapings examined for active and extensive 
invasion of the uterine tissues. Large nuclei, rich in chromatin 
and mitotic figures, together with a tendency on the part of the 



DIAGNOSIS OF HYDATIFOBM MOLE 189 

protoplasm to separate into individual cells or chains of cells, is, 
according to Voigt and Gottschalk, suggestive of malignancy. 

We are forced to the conclusion that as yet we have no certain 
means of making an absolute and early diagnosis of malignant 
degeneration of a hydatiform mole. The clinical signs, together 
with the gross and microscopic appearances, are all to be carefully 
considered. In view of our inability to make an absolute early 
diagnosis, vesicular degeneration of the chorion, however limited, 
demands immediate interference, to be followed by a period of at 
least three years of watchful expectancy; and if, at any time follow- 
ing the expulsion of the mole, hemorrhage recurs, the uterus is to 
be curetted and a microscopic examination made of the scrapings. 

Regarding the ^prognosis of hydatiform mole, experience teaches 
us to look with suspicion upon all cases even months and years 
after the removal of the mole. It is seldom that serious consequences 
occur while the mole is in utero. Malignant degeneration, rupture 
of the uterus, fatal hemorrhage — all these have occurred with the 
mole in situ, though such happenings are, fortunately, rare. We 
have learned to fear remote results — i. e., a repetition in subsequent 
pregnancies and malignant degeneration of retained chorionic epi- 
thelium. Heitzman estimated the mortality at 13 per cent. These 
statistics were gathered at a time when chorioepithelioma malignum 
was not recognized. It is generally accepted that 10 per cent, of 
hydatiform moles undergo malignant degeneration. This estimate 
is generally accepted as approximately expressing the death rate 
of hydatiform mole; but it is far too small, as shown by the follow- 
ing data. Deaths from hemorrhage and, to a lesser degree, from 
septic infection and rupture of the uterus add materially to the 
death rate, bringing the mortality to near 25 per cent. 

In my 210 cases collected from the literature there were 49 deaths 
— a mortality of about 25 per cent. Of this number 32 died from 
syncytioma malignum (16 per cent.); 7 died from hemorrhage (4 
per cent.); 4 died from septic peritonitis (2 per cent.); 1 died from 
general sepsis; 1 from uraemia; 1 from endocarditis and nephritis; 
1 from meningitis, and 2 from unknown causes. The author does 
not regard these statistics as expressing actual facts. There is 
doubtless a tendency to report all cases resulting fatally and to 
overlook those having no special point of interest in their course 
and termination. 



190 



SPECIAL DIAGNOSIS 



The later in pregnancy we have to do with Vesicular degenera- 
tion of the chorion the more grave the prognosis, because of the 
difficulty in removing the mole, the greater liability to rupture of 
the uterus, and to malignant degeneration. It has been stated, and 
will bear repetition, that the removal of a hydatiform mole is 
imperative as soon as the diagnosis is established. There can be 
no temporizing, however limited the vesicular degeneration and 
however early or late the condition is recognized. Where but a 
small area of the placenta is involved the diagnosis is not made 



Fig. 59 




Showing syncytial invasion of the stroma. 



until the termination of pregnancy; hence the question of inter- 
ference will not arise during pregnancy, but the same degree of 
watchful expectancy must be exercised after the termination of 
pregnancy. While all agree as to the disposition that should be 
made of the mole, it is always a grave question as to what should be 
our attitude toward the uterus after the mole is expelled. Solowiz 
has advised hysterectomy in all cases, and surely this would be the 
logical conclusion were we to agree with Van der Hoeven that all 
hydatiform moles are malignant. 



DIAGNOSIS OF HYDATIFOBM MOLE 191 

Recognizing the frequency of malignant degeneration of hydati- 
form mole, and finding our most reliable and early evidences in 
malignant invasion of the decidua, we indorse the advice of Butz, 
who would curette the uterus ten or twelve days after the expulsion 
of the mole, for the purpose of removing remaining fetal elements 
and of making a microscopic examination of the scrapings to detect 
a possible malignant invasion as shown by active proliferation of 
the chorionic epithelium. Doubt will occasionally arise after such 
a procedure, and where such doubt exists the uterus should be 
removed on suspicion. 

Respecting the influence of hydatiform mole upon future child- 
bearing, it is observed that healthy children are born subsequent 
to the expulsion of the mole, and that there does not appear to be 
acquired an added tendency to abortion. Contrary to the statement 
made by most text-books, it is the exception for a woman to give 
birth to more than one mole. In 210 recorded cases but two 
women gave birth to two moles, one to four (not recorded), one to 
five (not recorded), and one to eleven. It is furthermore seen that 
conception is possible very soon after the expulsion of the mole. 
On the other hand, a period of twenty years of sterility, and in two 
instances ten years, has preceded the development of the mole. 
It is correctly stated that multiparse are more liable to hydatiform 
mole than primiparte. In the 210 cases, 42 were primiparse, 139 
multiparse, and 29 not recorded. 



CHAPTER XXI. 

THE DIAGNOSIS OF CHOEIOEPITHELIOMA MALIGNUM. 

Introduction. 
Etiology. 

Clinical Diagnosis. 
Anatomical Diagnosis. 

From the fact that the histogenesis of this new-growth has until 
recently been httle understood, a number of names have been 
assigned to it. It was called deciduoma malignum, because it was 
believed to be a malignant proliferation of the decidua. Sarcoma- 
choriocellulare was a name suggested, on the theory that the essen- 
tial cell structures were of mesoblastic origin. On the other hand, 
the name carcinoma syncytiale was proposed, because of the sup- 
posed epithelial character of the growth. The term chorioepithe- 
lioma malignum more accurately expresses the true histogenesis 
of the growth, for it is now generally accepted that the growth is 
derived from the epithelial elements of the chorion and not from 
the decidua. (See Plate XXIII.) 

We are indebted to Sanger for our first knowledge of this tumor 
formation. In 1888 Sanger described such a case before the 
Obstetrical Society of Leipzig. He, however, believed the growth 
to be a malignant proliferation of the decidua, and classified it 
as a sarcoma. 

L. Fraenkel was first to demonstrate the origin of the growth in 
the epithelium of the chorion. He classified the tumor as a car- 
cinoma. 

The greatest and most important work on the subject is that of 
Marchand, to whom we are largely indebted for our present knowl- 
edge of the histogenesis and histology of chorioepithelioma malig- 
num. He it was who demonstrated that both the syncytium and 
Langhans' cells take part in the formation of the new-growth, and 
hence the fetal origin of the tumor, though occupying maternal 
tissues. 

( 192 ) 



DIAGNOSIS OF CHOBIOEPITHELIOMA MALIGNUM I93 

Peters demonstrated the true genesis of the epithelial layers of 
the chorion, Langhans' layer, and syncytium in his observations on 
an ovum five to six days old. He has demonstrated to the satis- 
faction of most observers that both the syncytium and Langhans' 
layers are derived from the ectoderm or trophoblasts, being his- 
togenetically identical. Holding to this view of the histogenesis 
of Langhans' layer and the syncytium, we are prepared to enter 
into a more intelligent discussion of the histology of the growth. 

ETIOLOGY OF CHORIOEPITHELIOMA MALIGNUM. 

In my analysis of 210 cases of hydatiform mole, I find that 16 
per cent, became malignant. It is stated that from 40 to 53 per 
cent, of chorioepithelioma malignum cases follow the expulsion of 
a hydatiform mole, 25 to 35 per cent, follow upon abortions, and 
20 to 25 per cent, follow upon full-term labors. Briguel collected 
181 cases of syncytioma malignum, in which 46 were preceded by 
normal labors, 55 by abortions, 76 by hydatid mole, and 4 by tubal 
pregnancy. It is seen that hydatid mole is particularly liable to 
undergo malignant degeneration. The time a hydatiform mole 
remains in utero has no influence upon the development of a malig- 
nant growth; there is the same liability to malignant transforma- 
tion in the early as in the later moles. 

In 124 cases collected by Ladinski the average age of the patient 
was thirty-two years — the extreme ages seventeen and fifty-five 
years. The greatest number occurred between twenty-seven and 
thirty-three years of age. In 90 cases collected by the same author 
the average number of children born was 4.2; hence multiparity 
has no influence upon the development of the growth. The time 
of the development of the growth in the placental site in relation 
to the expulsion of a hydatid mole, an abortion, or a full-term 
labor is two weeks to four and a half years. 

CLINICAL DIAGNOSIS OF CHORIOEPITHELIOMA MALIGNUM. 

The diagnosis must be based upon both clinical and histological 
investigations. There is almost invariably a history of pregnancy 
and the expulsion of a hydatiform mole, an undeveloped foetus, 
or a full-term foetus, weeks, months, and even years before the 
appearance of a malignant growth. 

13 



194 SPECIAL DIAGNOSIS 

The earliest symptom is hemorrhage. The loss of blood increases 
in amount and frequency, and very early causes profound anaemia. 
The usual means employed to check hemorrhage fail utterly, and 
may increase the flow. Persistent hemorrhage following upon an 
abortion or hydatid mole is suggestive of syncytioma. In curettage, 
the procedure must sometimes be abandoned because of the alarm- 
ing hemorrhage. 

A dirty, watery discharge occurs, together with and in the inter- 
vals between hemorrhages. Later this discharge assumes a foul 
odor. 

Pain is not a notable symptom. When present it is usually 
referred to the thighs and sacral region. 

Cachexia is an early development, following closely upon the 
anaemia. Loss of weight and strength is extreme. 

Symptoms referable to metastasis are early present — so early as to 
almost characterize the disease. In order of frequency metastatic 
growths are found in the lungs, vagina, liver, spleen, kidneys, 
ovaries, intestines, brain, broad ligament, pleura, lymphatic glands, 
pancreas, heart, stomach, and lymph glands of the pelvis. It is 
unusual for the metastatic growths to spread by way of the lymph 
glands, as is common with carcinoma. The cellular elements are, 
as a rule, conveyed by the blood stream, and in this respect behave 
like a sarcoma. 

Fever of a low grade is commonly present, and may reach 104° F. 
The pulse is correspondingly rapid and feeble. 

The above clinical signs are very significant, but not alone suffi- 
cient. The macroscopic and microscopic features of the growth 
must be considered before a diagnosis can be made with certainty. 

The macroscopic appearances of the growth are not character- 
istic. The uterus is almost always enlarged, and is commonly 
described as soft. In advanced cases there may be irregularities 
on the outer surface as well as on the inner. The cervix is usually 
patulous to the indfex finger, and in the cavity of the uterus may be 
felt a soft, brain-like mass, friable, and bleeding profusely when 
handled. To the naked eye this soft mass resembles at times 
placental tissue, and at other times a vascular sarcoma. The color 
of the growth is mottled red, varying from a bright to a dark shade. 
Necrosis early develops. The primary growth is not always con- 
fined to the uterus. Cases have been recorded where the uterus 



DIAGNOSIS OF CHOBIOEPITHELIOMA MALIGNUM I95 

remained free and a chorioepithelioma malignum developed in the 
vagina, lung, kidney, liver, brain, and spleen. (Vide infra.) 

The microscope is indispensable in determining the true character 
of the growth. Under the microscope we recognize a rapidly pro- 
liferating structure composed of syncytium and Langhans' cells, 
which invade the uterine tissue in a most typical manner, and 
early extend to distant portions of the body by way of the blood 
stream. 

After the expulsion of a hydatid mole the uterus should be explored 
by the finger to detect and remove any retained placental tissue. Two 
weeks later the uterus should be curetted and the scrapings examined 
microscopically. If in the decidua Langhans' cells and the syncytium 
are found to be proliferating, the uterus should be removed without 
delay. In every abortion or full-time labor when an unaccountable 
hemorrhage follows weeks and months afterward, an exploratory curet- 
tage should be done, in view of the possible finding of malignant 
placental tissue. 

The microscopic picture is that of strands of protoplasmic masses, 
with nuclei and vacuoles forming a reticular structure. Polynu- 
clear giant cells of syncytium are found in the network. 

The histological character of these growths differs widely. Two 
great classes are recognized by Marchand : the typical and atypical. 

The typical form assumes the character of the chorionic epithe- 
lium in the early placenta in that it presents a prolific growth of 
syncytium in a more or less established manner, together with a 
rather definite proportion of Langhans' cells. Not only may the 
epithelial elements be present in fairly definite proportions, but 
the entire villus, composed as it is of stroma and overlying epithe- 
lium, may be found in the tumor growth. In short there are found 
in the chorioepitheliomatous growths all the elements of the placenta 
as found in the early stages of pregnancy, and the arrangement of 
these elements as to number and location is not unlike those of 
the normal placenta. 

The atypical form presents a remarkable variety in its cellular 
structure and in the arrangement of these cells. The general 
arrangement of the elements in the normal placenta fails to appear. 
The shapes of the individual cells alone suggest placental tissue, 
and in this there are great variations. Some have been composed 
wholly of syncytium, others wholly of Langhans' cells. There is 



196 SPECIAL DIAGNOSIS 

such variation in structure that at times it is impossible to distin- 
guish Langhans' cells from syncytium. 

A feature worthy of special remark is the large quantity of blood 
in the primary and secondary growths. The blood lies between 
the cell elements and bathes them as in the case of the normal 
placenta, only here we find an exaggerated condition. A further 
analogy between the chorioepitheliomatous growths and the nor- 
mal placenta is the peculiar relation between the epithelial cells 
and blood fibrin. In both conditions fibrin layers are found between 
individual cells and groups of cells. The syncytial cells pene- 
trate vessel walls, blood is liberated, and as a consequence thrombi 
are formed in the bloodvessels, and there is a hemorrhagic infil- 
tration of surrounding tissues with the formation of fibrin. Fresh 
hemorrhages add to the mass by extending the blood spaces, and 
in this manner the rapid growth of the tumor is explained. The 
metastatic growths resemble the primary. 



PRIMARY CHORIOEPITHELIOMA MALIGNUM OUTSIDE OF 

THE PLACENTAL SITE. 

During the past seven years 20 cases of primary chorioepithe- 
liomata arising in women outside the placental site have been 
reported, and to this number I have added the report of a case 
that was primary in the uterine musculature. 

In the recorded 21 cases unmistakable chorioepitheliomatous 
tumors have been observed in locations remote from the placental 
site of the uterus and Fallopian tubes. In no case has it been pos- 
sible to trace a direct anatomical connection between the placental 
site and the primary tumor. 

In nearly all cases it has been possible to trace a direct clinical 
relation between pregnancy and the tumor formation. These 
tumors have arisen during the course of pregnancy, at varying 
intervals after the completion of normal pregnancy, following com- 
plete and incomplete abortions, while hydatiform moles were in 
situ and a variable time after their expulsion. In no instance has 
such a growth been recognized in a nullipara, though in one instance 
the appearance of the tumor followed the establishment of the 
menopause. 

In primary chorioepithelioma of the placental site the vagina 



X 
X 

w 

< 










a 




o 

>> 

03 






DIAGNOSIS OF CHOBIOEPITHELIOMA MALIGNUM I97 

is most often the seat of secondary invasion by metastasis. It is 
also true that primary extrauterine chorioepithehoma arises with 
greatest frequency in the vaginal walls. This is an exception to 
the rule that tissues which are a common seat of primary malig- 
nant growths are seldom a seat of secondary invasion by these 
growths. The following presents the topographical distribution 
of the chorioepitheliomata in regions not connected with the placen- 
tal site: vagina, 14; lungs, 8; liver, 5; brain, 5; kidney, 5; uterine 
musculature, 3; intestine, 3, and 1 each in spleen, thyroid, supra- 
renal gland, retroperitoneal lymph gland, heart muscle, ovary, 
bladder, labium, and mediastinum. 

It was not always possible to identify the primary growth apart 
from the secondary metastatic growths. The vagina was believed 
to be the primary seat in 11 cases; the uterine musculature in 3 
cases; the cervix, brain, kidney, and labium each in 1 case. In 
the remaining 3 cases it was not possible to identify the primary 
growths. The size was not found to be a safe guide in judging 
the priority of the growths. For example, in the case reported 
by Fiedler the primary growth in the uterine musculature was the 
size of a cherry-stone, while in the liver there was a secondary growth 
the size of a child's head. 

Undoubtedly small metastatic growths in various portions of the 
body are frequently overlooked, and subsequently disappear spon- 
taneously. They are known to vary in size from that of a hazelnut 
to a child's head, and in number from one to a score or more. 
Multiple growths in the same organ or tissue have been repeatedly 
described, and in all cases there was an almost uniform appearance 
in the gross structure. In general, they have presented the macro- 
scopic appearance of blood clots. As a rule, they were of firm 
consistency, bluish-red in color, and on cross-section presented a 
fibrinous-like character in the centre of the blood coagulum. 

In the vagina the overlying mucosa was frequently ulcerated, and 
through the defective covering blood escaped. Occasionally the hem- 
orrhage was so great as to require tamponing or immediate operation. 

In all cases of primary vaginal growths the hemorrhage was at 
first thought to come from the uterus, but direct inspection readily 
located the seat of hemorrhage in the vaginal tumor, and a subse- 
quent exploratory curettage, with microscopic examination of the 
scrapings, excluded the presence of the growth in the uterus. 



198 SPECIAL DIAGNOSIS 

Krebs and E. Fraenkel reported cases in which no hemorrhage 
occurred. 

A case of Brault, reported as "sarcoma angioplastique," was 
doubtless a chorioepitheHoma maUgnum, primary outside of the 
placental site. In the liver was a tumor the size of an orange, and 
presenting the appearance of a large red blood clot. Smaller ones 
of similar structure were found in the stomach, lungs, and lymph 
glands. No lesion was found in the uterus and adnexje. Histo- 
logically, the growth was composed of protoplasmic masses, which 
were rich in nuclei and very irregular in outline. These were 
vacuolated. Numerous smaller polyhedric cells, with single nuclei 
resembling Langhans' cells, were intimately associated with the 
protoplasmic masses. 

The decidual changes in the uterine mucosa in the cases of 
Schmorl, Fiedler, and Holzapfel are remarkable. The decidua was 
not unlike the decidua vera of normal pregnancy, and averaged 
f cm. in thickness. We recognize here an analogy to the decidual 
formation of ectopic pregnancy. 

Histogenesis. It is interesting to speculate on the genesis of 
these growths. We ask. Was the placental tissue malignant when 
in utero, and had metastatic invasion been instituted prior to a 
complete expulsion of the malignant placental tissue from the 
uterus? Can we conceive of a complete spontaneous expulsion of 
malignant placental tissue from the uterus — i. e., self-elimination 
of the original uterine tumor while the metastatic growths remain 
in distant portions of the body and continue to develop? Is spon- 
taneous involution of the original uterine tumor possible? Is it 
possible that the primary growth at the placental site was removed 
by the curette or finger? 

These are interesting and very important questions, which must 
remain for future investigations to answer. 

It has been shown conclusively by Webster, Veit, Pick, and later 
observers that not only chorionic epithelium, but the entire villus 
as well, is carried to distant parts of the body through the blood 
stream, and this under perfectly normal conditions. 

May these deported elements proliferate to form tumor growths 
which may be benign in one case, malignant in another, and leave 
the uterus free from tumor formation? 

With our present knowledge of the placenta we cannot solve 



DIAGNOSIS OF CHORIOEPITHELIOMA' MALIGNUM I99 

these problems. Macroscopic and microscopic examinations of 
the expelled placenta, of hydatiform mole, and of scrapings from 
the placental site afford no information, because we cannot distin- 
guish a malignant from a benign growth of the epithelial elements 
found in these structures. 

Neumann's statement that malignancy is recognized by the 
epithelial invasion of the stroma of the villus has been disproven. 

The atypical growth of syncytium with large and richly chro- 
matic nuclei has been regarded by Gottschalk and others as 
indicative of malignancy; but this too has been disproven. 

The proliferation of Langhans' cells and their atypical distribu- 
tion were thought by Voight to suggest malignancy, but subsequent 
investigations fail to substantiate his views. 

Primary chorioepitheliomatous growths outside of the placental 
site have developed where macroscopic examinations of the 
expelled mole or placenta showed none of these features (Pick, 
Guerard). 

The fact that syncytium under normal conditions is known to 
disappear spontaneously from uterine and other tissues leaves the 
question open as to the possibility of malignant chorioepithelioma 
spontaneously disappearing from the uterus. 

Under perfectly normal conditions we see the syncytium rapidly 
proliferating, destroying tissues as it advances, burrowing into 
bloodvessels, and carried to distant portions of the body. For all 
we are now able to judge, the difference in the behavior of normal 
syncytium and the malignant type is one of degree in its prolifer- 
ating tendencies. It is probable, as Risel has suggested, that the 
difference between the benign and the malignant syncytial growth 
does not lie in these elements, but is dependent on the peculiar 
resistance of the tissues invaded. We find every possible gradation 
between the normal placenta, the hydatiform mole, and chorio- 
epithelioma malignum, and a transition from one to the other in 
the order named is possible. 

Permanent healing has followed the removal of the growths, and 
even the partial removal, as in the case of Fleischmann, in which 
a secondary vaginal tumor was removed, and only a portion of 
the primary uterine tumor removed by the curette. Yet not only 
did the uterine tumor completely disappear, but there was subse- 
quent childbearing and complete recovery. 



200 SPECIAL DIAGNOSIS 

The microscopic examinations of the tissues scraped from the 
uterus showed what appeared to be a typical chorioepithehoma 
maHgnum. 

We therefore are forced to the conclusion that we have no way of 
judging the malignancy of these growths save hy the subsequent 
course of the case. 

Schlagenhaufer and, about the same time, but independently, 
Wlassow observed chorioepitheliomatous growths in the testicle 
identical to those found in the female. These growths are regarded 
by the above observers to have the same histogenesis — i. e., that 
they arise from embryonic elements of the fetal ectoderm and con- 
tain both syncytium and Langhans' cells. Wlassow examined 
twelve teratomata of the testicles and found this peculiar cell 
structure in three. 

L. Pick has since found a similar structure in ovarian tissue. 
Risel, Schmorl, and Steinhaus have made further observations in 
cases of chorioepithehoma malignum of the testicle. It is possible, 
though not yet proven, that such tumors may occur elsewhere in 
the male. 

Breus (1878) recorded a testicular tumor, with a secondary tumor 
in the heart, which Schlagenhaufer regarded as a malignant hyda- 
tiform mole in the male, and Breus later accepted his views as 
highly probable. In view of this case and the other testicular 
tumors reported by Schlagenhaufer, Risel, Schmorl, Wlassow, and 
Steinhaus the question naturally arises. What light does this throw 
on the origin of teratomata and on the chorioepitheliomata in 
women? Certainly it establishes the theory of the fetal origin of 
these growths, as opposed to the theory of the maternal origin. 
Furthermore, the epithelial covering of the villi must be regarded 
as being epiblastic in origin. 

It is probable that in the antenatal period, when the foetus is 
little more than a segmentation sphere, one or more polar bodies 
or blastomeres become displaced and incorporated in the structures 
which go to make the testicle, and later develop into structures 
comprising all three layers of the blastoderm. 

Why a complete embryo is not developed and why the growth at 
times becomes malignant are unsolved problems. 

Diagnosis. From a study of these cases it is observed that the 
clinical diagnosis of primary chorioepithehoma has only been made 



DIAGNOSIS OF CHOBIOEPITHELIOMA MALIGNUM 201 

in the cases where the lesion could be directly inspected — i. e., in 
the vagina, labium, and cervix. They were recognized by their 
characteristic rounded shape and bluish color, their tendency to 
bleed freely, and by the absence of uterine hemorrhage, together 
with negative findings in the uterus, after exploring with the finger 
and curette. 

The clinical diagnosis was at all times confirmed by microscopic 
examinations of portions of excised or curetted tissue. Without 
the microscope a positive diagnosis is not possible. 

Tumors lying in hidden portions of the body — e. g., kidney, liver, 
and lung — ^were not diagnosed with certainty without a post-mortem 
examination. 

Where the case did not end fatally it was not possible to say that 
the growth was malignant, from the fact that the macroscopic and 
microscopic findings in these growths were in no way diagnostic of 
malignancy. 

The ages at time of operation were twenty to fifty years. Twelve 
of the seventeen cases in which the age was recorded occurred 
between thirty-five and forty-one years of age. 

We find in this number that in one case a hydatiform mole was 
in utero at the time of appearance of the symptoms and primary 
growth. In another case there was a two months' foetus in utero. 
In these cases the tumor followed incomplete abortions; in three 
others the abortions were complete, and in seven cases there were 
normal labors. 

In all cases where there were vaginal or cervical tumors, hemor- 
rhage was the symptom which led to the detection of the growth. 
In exceptional cases a foul-smelling vaginal discharge followed the 
appearance of the hemorrhage. 

From the fact that these growths are so frequently located in 
the vagina, and that hemorrhage is an early and constant symp- 
tom, our suspicions should always be aroused by the occurrence 
of bleeding from the vagina during the course of pregnancy after 
the expulsion of a hydatiform mole, an abortion, or labor. 

If on inspection such a tumor is found it should be excised, 
and if on microscopic examination chorionic epithelium is found an 
exploratory curettage of the uterus should be made. However, we 
have learned that we cannot rely on the microscopic findings in 
the scrapings in determining the malignancy; hence, because of 



202 SPECIAL DIAGNOSIS 

our present limitations, it would appear to be advisable to make a 
complete extirpation of the uterus when syncytial tissue is found 
in the scrapings. The cases which have recovered after the re- 
moval of the vaginal growth and leaving the uterus do not, in our 
present knowledge of these cases, justify us in leaving the uterus 
unless by an exploratory curettage the uterus is found free from all 
chorionic epithelium. 

The relation of hydatid mole to chorioepithelioma malignum is 
discussed in the chapter on Hydatiform Mole. 

The diagnosis of the malignant character of a chorioepithelioma 
cannot be based upon the macroscopic or microscopic appear- 
ances of the growth, nor will the presence of metastatic growths 
confirm the diagnosis. The histological and naked-eye appear- 
ances are the same in the benign as in the malignant forms, and 
metastatic growths have been known to disappear spontaneously. 
We therefore must rely upon the ultimate clinical course for the 
diagnosis of malignancy. 



CHAPTEE XXII. 

THE DIAGNOSIS OF MALFORMATIONS OF THE UTEEUS. 

I. Those Due to Imperfect Development of Muller's 
Duct. 

1. Uterus Deficiens. 

2. Uterus Rudimentarius. 

3. Uterus Foetalis (Infantile Uterus). 

4. Uterus Unicornis. 

II. Those Due to Imperfect Blending of Miiller's Duct. 

1. Uterus Septus (Bilocularis). 

2. Uterus Bicornis. 

3. Uterus Didelphys (Uterus Duplex, Uterus Separatus). 

4. Uterus Accessorius. 

The developmental defects of the uterus are arranged under two 
general headings: 

1. Those due to imperfect development of Miiller's ducts. 

2. Those due to imperfect blending of the same. 

UTERUS DEFICIENS. 

It is very unusual to find in an adult a complete absence of the 
uterus. When found there is usuallv also an absence of the entire 
genital tract, or only a rudimentary development of the vulva, 
vagina, tubes, and ovaries. The round ligaments may be present, 
though poorly developed. If the ovaries are present the menstrual 
molimina will be experienced, and vicarious menstruation may 
occur. There may or may not be sexual desire. 

It has been found in such malformations as acephalia, but to find 
no trace of the uterus in viable foetuses or adults is indeed rare. 
A bilobed uterus has been mistaken for the Fallopian tubes, and 
a hollow rudimentary uterus for the vagina in post-mortem ex- 
aminations. 

There may be no evidence of a uterus other than a thickening 
of the posterior vesical wall, or a smooth band continuous above 

(203) 



204 SPECIAL DIAGNOSIS 

with the tubes and below with the round hgaments, or the broad 
ligaments may be thickened in places by uterine tissue. It is mani- 
festly impossible to make a clinical distinction between such rudi- 
mentary conditions and complete absence of the uterus. Mistakes 
have been made in anatomical dissections. 

The ovaries are often normal. In fact, the general psychical and 
physical development is usually perfect. 

Periodic ovulation seldom occurs. A scanty bloody discharge 
rarely comes from the vagina, and has not been demonstrated to 
be a menstrual flow. Vicarious hemorrhages from the nose and 
rectum have been reported. 

The condition is usually recognized in the effort to determine 
the cause of amenorrhoea and sterility. The examination is best 
made per rectum. A sound placed in the bladder can be palpated 
along its entire course by the finger in the rectum. If the uterus 
were well developed this would be impossible. 

The differential diagnosis between a complete absence of the 
uterus and a rudimentary uterus is scarcely possible without mak- 
ing an exploratory incision. Placing a sound within the bladder 
and directing an assistant to hold it while proceeding with a recto- 
abdominal examination will demonstrate either an entire absence 
or a rudimentary development of the uterus (Fig. 14). 

UTERUS RUDIMENTARIUS. 

As the name implies, the uterus is rudimentary in its develop- 
ment. It remains as a fibromuscular body, ill formed and under- 
sized. The walls may be so thin as to suggest the name uterus 
membranaceous. The cervix, adnexse, ligaments, and vagina are 
likewise rudimentary or absent. The external genitals may be 
well formed, though this is not probable. As stated in the above 
paragraph, a diagnosis cannot be made from complete absence of 
the uterus unless by abdominal section. 

UTERUS FCETALIS (Infantile Uterus). 

The uterus and adnexse fail to develop beyond that of fetal life 
or early infancy — they are undersized. No sharp distinction can 
be made in these cases. In general it may be stated that when the 



DIAGNOSIS OF MALFORMATIONS OF THE UTERUS 205 

cervix is larger than the corpus uteri, the walls thin, and the long 
axis of the uterus less than two inches, we have to do with an infan- 
tile uterus. A better term would be hypoplasia uteri. Congenital 
anteflexion of the uterus is usually due to hypoplasia of the uterine 
wall at the point of flexion. Aside from the size, the most striking 
feature of the fetal or infant uterus is the disproportion between 
the cervix and the body of the uterus. The cervix is two-thirds 
the length of the whole organ, the body one-third. In the mature 
uterus the cervix is one-third the length of the whole organ, the 



Fig. 60 




a, ribbon-shaped rudiment of the uterus ; b, b, roiind ligaments; c, c. Fallopian tubes; 

d, d, ovaries. (Mann.) 



body two-thirds. Again, the arbor vitse in the fetal or infantile 
uterus extends the entire length of the uterine cavity, while in the 
adult uterus the mucosa of the body is smooth and the arbor vitse 
extends only the length of the cervix. Still another feature of the 
fetal or infantile uterus is the absence of a fundus; the top of the 
uterus is either flat or depressed, while in the adult uterus it is convex. 
The vagina is usually shorter and narrower than is normal, but 
as a rule is well formed. The vulva may be poorly developed and 
the breasts likewise, but this is not the rule. 



206 SPECIAL DIAGNOSIS 

A general hypoplasia of the whole cardiovascular system is said 
to be an underlying factor in this developmental failure. Chlorosis, 
scrofula, and the general wasting diseases are given as general pre- 
disposing causes. No general cause can account for local hypo- 
plasia where the other structures of the body are well developed. 
Cretins and dwarfs commonly possess fetal or infantile uteri, but 
not infrequently there is perfect general physical development. It 
is probable that the developmental failure lies primarily in the 
ovaries. 

The clinical diagnosis is not difficult. Primary amenorrhoea 
should always suggest the probable existence of an infantile uterus. 
Sterility is invariably present. If the patient has menstruated 
normally, or if she has ever been pregnant, there is no possibility 
of an infantile or fetal uterus. A small vagina and vaginal por- 
tion of the cervix suggest a small uterus. A rectoabdominal exam- 
ination under anaesthesia is preferred. When the uterine canal will 
admit a sound the measurement of the length of the uterus may be 
made, and an estimate of the thickness of the wall can be arrived 
at by a conjoined rectoabdominal examination, the sound remaining 
in the uterus. 

UTERUS UNICORNIS. 

But a single horn of the uterus is developed; the opposite horn 
is either absent or rudimentary. 

The explanation of this defect lies either in a partial or complete 
failure of one Miillerian duct to develop. The single horn tapers 
off into the tube. At the juncture of the horn and the tube the 
round ligament is given off. There is no fundus. The vagina and 
cervix are small, and may be divided partially or completely by a 
septum. The ovaries and tubes may be rudimentary or absent; 
so, also, the bladder and kidney may be undeveloped, or there may 
be absence of the kidney on the side opposite the single horn. The 
cervix is small and the virgin vagina is narrow. The deformity is 
difficult to distinguish clinically from the infantile uterus. The 
lateral deflection of the uterus is highly suggestive. 

Sterility is the rule, though pregnancy in a rudimentary horn is 
possible. Amenorrhoea is common, but the menstrual functions may 
proceed regularly. Where pregnancy exists in a rudimentary horn 
we have to deal with a condition not unlike tubal pregnancy in its 



DIAGNOSIS OF MALFORMATIONS OF THE UTERUS 207 

clinical aspect. The dangers of rupture and of hemorrhage are 
the same. There is no way of making a distinction between these 

Fig. 61 




Uterus unicornis: L H, left horn; L T, left tube; L o, left ovary; R R, right horn; R T, 
right tube; R o, right ovary; B L r, right round ligament; L L r, left round ligament. 
(Mann.) 

Fig. 62 




Uterus septus duplex (natural size), completely double uterus, and incompletely double 
vagina of a girl twenty-two years of age : a, a, tubes ; b, b, fundus of the double uterus ; 
c, c, c, partition of uterus ; d, d, cavities of the uterine bodies ; e, e, internal orifices ; /, /, 
external walls of the two necks ; g, g, external orifices ; h, h, vaginal canals ; i, partition 
which divided the upper third of the vagina into two halves. (Mann.) 



208 SPECIAL DIAGNOSIS 

two conditions save by abdominal section, unless, as is possible in 
exceptional cases, the gestation sac is demonstrated by abdominal 
palpation to lie within the attachment of the round ligament. In 
tubal pregnancy, the gestation sac lies external to the attachment 
of the round ligament. 

UTERUS SEPTUS (Bilocularis). 

The uterus is divided by a vertical septum extending a variable 
distance from the external os to the fundus. On the exterior there 
is no evidence of a septum. 

The uterus is broader and more globular than is the perfectly 
developed organ. Not infrequently the vagina is septate. Various 
explanatory terms have been applied to the several degrees of the 
septate uterus — i. e., uterus bijoris supra simplex, where the septum 
is only found near the external os; uterus suhseptus unicorporenSy 
where the septum is found in only a part of the cervix and body; 
uterus suhseptus unicellis, where the septum is found in the body, 
not in the cervix; and uterus suhseptus uniforis, where the sep- 
tum completely divides the body and cervix, there being a single 
external os. 

UTERUS BICORNIS. 

The two horns of the uterus are united to a limited and variable 
degree, the union taking place from below upward. The two halves 
of the uterus are rarely equally developed. All gradations are 
observed between the uterus unicornis with a rudimentary second 
horn and the uterus bicornis with both horns fully developed. The 
tubes and ovaries are usually normal, but the vagina often partici- 
pates in the duplexity. The degree of separation varies'from com- 
pletely divided bodies with a single cervix to a union of the two 
horns, leaving but a notch in the fundus. The two horns are not 
always of equal size, and may not lie on the same plane. A septum 
may partially or completely divide the cervix and vagina. One 
or both horns may be imperforate. The external genitals are 
usually normal (Fig. 63). 

In addition to the anomalies in the development of the genital 
organs there may be maldevelopments of the urinary tract — e. g., 
ectopia vesicae, absence of or congenital atrophy of the kidney. 



BIAGNOSIS OF MALFORMATIONS OF THE UTERUS 209 

The behavior of the uterus bicornis is similar to that of the 
uterus septus. Menstrual disorders are common. Amenorrhoea 
may result from atresia of the lower genital tract, or from an 

Fig. 63 











iK^ 


^^ 








J 


i^^i^^K MMHHK . '^■i^Si 


^BSki^i^HlillKwI^MlffiiB 




^ 




1* ' 




^^1^^ ' MMkJ^JwSyggSM P ' 


^F 



Bicornate uterus with bilateral tubo-ovarian abscesses. The specimen was removed 
post-mortem. The patient refused operation and died of general suppurative peritonitis. 
Four children had been born, probably from the larger horn. 




Uterus bicornis unieellis : a, vagina laid open ; b, single cervix ; c, c, uterine horns ; 
/,/, round ligaments ; d, d, Fallopian tubes; e, e, ovaries, (Mann.) 

14 



210 



SPECIAL DIAGNOSIS 



imperforate lumen in both horns of the uterus. The menses may 
flow simuhaneously from the two horns or alternately at intervals 
of from two to four weeks. When one horn or one-half of a septate 
uterus is pregnant the opposite side may continue to menstruate 
or may become pregnant at any time during the period of gesta- 
tion in the other side. A decidua may form in the non-gravid side 
and be discharged at labor. Pregnancy and labor may progress 
normally, and uterine contractions occur in both horns. This, 
however, is not the rule. The uterine contractions are seldom 
regular and strong; malpositions and malpresentations of the child 
are common; placenta prsevia and premature detachment of the 
placenta may occur at any time, and rupture of the uterus during 
labor is always to be feared. 



Fig. Go 




Double uterus (uterus didelphys): a, right cavity; &, left cavity; C, right ovary; d, right 
round ligament; e, left round ligament; /, left tube; g, left vaginal portion; h, right 
vaginal portion ;. i, right vagina ; j, left vagina ; k, partition between the two vaginae. 
(Mann.) 



The presence of the uterus bicornis or uterus septus is often not 
suspected, even after marriage and childbirth. A double vagina 
or a double cervix will suggest the presence of a septate or bicornate 
uterus. When pregnancy does not exist the finger or sound will 
aid in the diagnosis. Under anaesthesia the separate horn may be 
detected by bimanual examination. Involution is rarely so perfect 
in the puerperium as in the normal uterus, and there are likely to 



BIAGNOSIS OF MALFORMATIONS OF THE UTERUS 211 

follow displacements and subinvolution with all their remote con- 
sequences. Placental tissue is liable to be retained in the uterus 
and lead to infection and hemorrhage. 



UTERUS DIDELPHYS (UTERUS DUPLEX, UTERUS SEPARATUS). 

Not only the uterine horns but the cervix as well is completely 
divided. Each half is equipped with a single tube, ovary, and 
round ligament. The vagina may be single, double, or partially 
divided. The two halves may be in different planes and of unequal 
size. One or both sides may be imperforate. All that has been 
said of the clinical features of a bicornate uterus will apply to a 
uterus didelphys. 

UTERUS ACCESSORIUS. 

This is the rarest of anomalies in the development of the uterus. 
Hollander and Skene each observed a case in which a small uterus 
was situated in front of a normal uterus, the two bodies joining 
at the internal os. The accessory uterus had no adnexse and no 
round ligaments. The explanation of this anomaly is probably 
that a diverticulum of Miiller's duct developed into an accessory 
uterus. Hollander's case gave birth to seven children. In an 
abdominal section placental tissue was found in the accessory 
uterus. Skene's case suffered from a leucorrhoeal discharge from 
the accessory organ. 



CHAPTEE XXIII. 

THE DIAGNOSIS OF MALPOSITIONS OF THE UTERUS AND ITS 

NEIGHBOEING ORGANS. 

Pathological Mobility. 

Pathological Fixation. 

Anteposition. 

Retroposition. 

Lateroposition. 

Elevatio Uteri. 

Torsion. 

Prolapsus Uteri. 

Inversion. 

Anteversion. 

Anteflexion. 

Retroversioflexion. 

Under perfectly physiological conditions the uterus may occupy 
widely varying positions. In order that these physiological changes 
in position may occur, the uterine ligaments, pelvic peritoneum, 
and cellular tissue must possess their normal degree of elasticity 
(Fig. 66). 

The normal position of the uterus varies with the attitude of the 
individual. It is crowded backward by a full bladder, forward by 
a loaded rectum, and forward and downward by increase in the 
intra-abdominal pressure from coughing, straining at stool, etc. 
• By reference to Figs. 68 and 69, it will be seen that the normal 
position of the uterus of a virgin in the erect posture, with the 
bladder and rectum empty, is one of anteversion, slight ante- 
flexion, anteposition, and slight lateral position. The body of the 
uterus lies about 1 cm. behind the upper border of the symphysis 
pubis, the cervix points to the second sacral vertebra, and lies about 
2 cm. in front of the sacrococcygeal articulation. In the virgin 
there is less anteflexion than in a multipara. The explanation lies 
( 212 ) 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 213 

Fig. 66 



Ureter. 

Obturator 
artery. 




Internal iliac 

artery. 
External iliac 

artery. 

Vesicovaginal 
artery. 



The uterosacral ligaments or folds of Douglas. (Testut.) 



Fig. 67 





9 11 

Coronal section of the uterus of a nuUip- Coronal section of the uterus of a multip- 

arous woman. arous woman. 

1, fundus; 2, lateral walls of the body; 3, cervix; 4, isthmus; 5, cavity of the body; 5', 
internal wall of the body; 6, cornu; 6', opening of the Fallopian tube; 7, arbor vitse; 8, os 
internum; 9, os externimx; 10, 10', lateral fornices; 11, posterior vaginal wall. (Testut.) 



214 



SPECIAL DIAGNOSIS 



in the fact that the small resisting vagina presses the slender 
cervix backward (Figs. 67 and 68). 



Fig. 69 




Normal position of the uterus. The uterus lies anteposed, anteverted, and slightly ante- 
flexed when the bladder and rectum are empty and the patient in the upright position. 

Pathological changes in the position of the uterus and its neigh- 
boring organs are more or less permanent. There is no tendency 
toward a spontaneous return to the normal position. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 215 

PATHOLOGICAL MOBILITY OF THE UTERUS. 

The uterus becomes abnormally movable when the normal sup- 
ports are weakened or have given way. A relaxation of the uterine 
ligaments, of the pelvic floor, and of the abdominal muscles will 
lead to abnormal mobility of the uterus. Under such conditions 
the uterus gravitates according to the position of the patient. In 
the upright position, with the bladder empty, it may fall forward 
and downward. In the dorsal position with the rectum empty, 
the uterus falls backward into the hollow of the sacrum. This 
condition when uncomplicated cannot be regarded seriously from 
a clinical point of view. 

PATHOLOGICAL FIXATION OF THE UTERUS. 

An abnormally movable uterus may lodge in a position where it 
becomes fixed and immovable. It is thereby evident that the fac- 
tors causing increased mobility of the organ may lead to a more or 
less permanent fixation. Fixation of a misplaced uterus will be 
considered in subsequent chapters. We will here discuss only 
fixation of the normally placed uterus. By this we mean a uterus 
in normal position but lacking the degree of elasticity and mobility 
that is found in health. 

Parametritis atrophicans (Freund) or parametritis posterior 
(Schultze) is a condition frequently overlooked. The uterosacral 
ligaments are firmly contracted and tender. By thickening and 
contraction of the uterosacral ligaments the cervix is drawn back- 
ward and the whole uterus restricted in its movements. A chronic 
metritis will diminish the normal flexibility of the uterus, as may 
also carcinoma and fibroids. Chronic cervical catarrh may stiffen 
the cervix. 

ANTEPOSITION OF THE UTERUS. 

Anteposition is an exaggeration of the normal position. The 
uterus lies immediately behind the abdominal wall and symphysis 
pubis. Among the causes of anteposition of the uterus we have 
swellings behind, crowding the uterus forward, or adhesions attached 
to the anterior surface of the uterus, pulling it forward, such as are 
made by ventrofixation. The latter condition is very unusual. 



216 SPECIAL DIAGNOSIS 

The most common causes are tubal and ovarian swellings lying 
in the cul-de-sac of Douglas, retrouterine Iwematocele, tumors of 
the uterus bulging from the posterior surface of the uterus, and 
new-growths of the rectum. Anteposition is often combined with 
elevation, anteversion, and anteflexion. 

The diagnosis is seldom difficult. On bimanual examination the 
uterus is found lying close to the anterior abdominal wall. When 
caused by retrouterine swellings which cannot be outlined apart 
from the uterus the sound will be required to locate the position of 
the organ. A retrouterine tumor crowding the uterus forward is 
recognized by its irregular outline and its consistency. Here, again, 
the uterine sound will be of service in locating the uterus. In every 
doubtful case an anaesthetic should be administered. The one symp- 
tom commonly present is frequent urination. (See Plate XXV.) 
Anteposition of the uterus is but an exaggerated normal position, 
and is not to be regarded seriously. The determining factors and 
associated lesions as above named alone demand serious considera- 
tion. 

RETROPOSITION OF THE UTERUS. 

In retroposition the uterus lies back of the normal position with- 
out change in the direction of its long axis. 

As causes of retroposition we find either a swelling in front of 
the uterus or adhesions behind it. Among swellings in front of the 
uterus are uterine fibroids, tumors of the bladder and anterior 
abdominal wall, persistent distention of the bladder, and, occasion- 
ally, distended tubes and ovaries. Adhesions behind the uterus 
causing retroposition are largely confined to the peritoneal cavity, 
and involve the greater portion of the posterior surface of the 
uterus. These adhesions most frequently result from extension of 
an inflammation from the tubes, which when inflamed commonly 
lie behind the uterus. In abnormal mobility of the uterus due to a 
relaxation of the normal supports the uterus falls into retroposition 
when the patient lies upon her back. (See Plate XXVI., Fig. 1.) 

It is most important to recognize the cause of the displacement, 
inasmuch as retroposition per se is of little clinical significance. 
When no tumor mass or adhesions are found in the pelvis and the 
retroposed uterus displays an abnormal mobility the displacement 
is regarded as due to relaxation of the uterine supports. 



PLATE XXIV. 




Retrouterine Haematoma Crovvding the Cul-de-sac of 

Douglas Up and the Uterus Up^A/^ard 

and Forward. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 217 

It is not always possible to diagnose the presence of adhesions, 
even when the examination is made under anaesthesia. All operators 
of experience will testify to the frequency with which perimetritic 
adhesions are unexpectedly found after opening the abdominal 
cavity. This fact alone would seem to render the Alexander opera- 
tion of shortening the round ligaments through the inguinal canal 
an uncertain procedure. 

Perimetritic adhesions are confined to surfaces normally covered 
with peritoneum. They are found with the greatest frequency 
about inflamed tubes and ovaries, and are therefore most commonly 
located beside or behind the uterus. The uterus is rarely absolutely 
fixed. The degree of mobility depends upon the location of the 
adhesions, their extent, length, and firmness. Adhesions binding 
the uterus to movable structures, such as bowel and omentum, 
usually permit more or less mobility on the part of the uterus. 
The diagnosis of a perimetritic exudate — that is, of an exudate 
lying within the peritoneal cavity and binding together the peri- 
toneal surface of the uterus with the peritoneal surface of the adja- 
cent structures from an exudate involving the pelvic cellular tissue 
— is made first of all by the location. A parametritic exudate lies 
low in the pelvis in close proximity to the vaginal wall, while a 
perimetritic exudate lies on a higher plane and is more difficult 
to palpate through the vagina. Furthermore, in parametritis the 
adhesive bands are firmer and larger than in perimetritis. The 
uterine sound may be of service in locating the position of the 
uterus apart from inflammatory exudates and new-formations. 

LATEROPOSITION OF THE UTERUS. 

Lateroposition is generally combined with retroposition, less often 
with anteposition and descensus. A limited lateral displacement of 
the uterus may be regarded as normal, and is explained by a short- 
ening of the broad ligament on the side to which the uterus leans. 
This congenital unilateral shortening of the broad ligament and also 
of the uterosacral ligament accounts for the lateral displacement of 
the uterus not infrequently found in virgins. 

The usual causes of lateral displacements of the uterus are 
inflammatory exudates and new-formations; more rarely cica- 
tricial contractions of the vaginal wall following lacerations and 



218 



SPECIAL DIAGNOSIS 



sloughs. Exudates at the sides of the uterus, when large, will 
crowd the organ to the opposite side of the pelvis. Later, as the 



Fig. 70 




Left laterodisplacement of the uterus. The left broad ligament is thickened and contracted 

and has drawn the uterus to the left. 

Fig. 71 




Left lateroversion of the uterus. The uterus is crowded to the left side of the pelvis, the 
long axis of the uterus inclines to the left. The cause of the displacement is a broad liga- 
ment cyst of the right side adherent to the wall of the pelvis. 



exudate organizes and contracts, the uterus is drawn to the side 
occupied by the exudate (Fig. 70). If the exudate exerts its 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 219 

influence along the entire side of the uterus, the uterus as a whole 
will be first pushed to the opposite side, and later drawn to the 
same side. If the exudate inv'olves the lower segment of the 
broad ligament, leaving the body of the uterus free and movable, 
the cervix will be drawn toward the side in which the exudate has 
collected and the body of the uterus tilted to the opposite side — a 
lateroversion or lateroflexion. Likewise, in case of tumor forma- 
tions lying beside the uterus, if the force is distributed along the 
side of the uterus there will be a simple lateroposition ; if pressure 
is exerted upon the fundus alone, there will be a lateroversion or 
flexion in which the body will be crowded to the opposite side, the 
cervix pointing to the side occupied by the tumor (Fig. 71). 

Slight lateral displacements of the uterus are commonly over- 
looked. When found they should always lead to a careful bimanual 
examination, and, if necessary, under anaesthesia, in view of deter- 
mining the cause of the lateral position. Reference to Figs. 70 
and 71 will suggest in a general way the mechanism of the dis- 
placement. In a word, the displacement is due to traction on the 
one side or to crowding on the other. 

ELEVATIO UTERI. 

In elevatio uteri the uterus is raised above the normal plane and 
approaches the anterior abdominal wall. In uncomplicated elevatio 
uteri the long axis of the uterus is straightened. As a matter of 
fact, it is unusual to find an uncomplicated elevation of the uterus, 
such a condition being, as a rule, associated with lateral, anterior, 
or posterior displacements. The position is physiological in preg- 
nancy. The extent to which the uterus may be drawn upward is 
astonishing. A perfectly normal uterus may be raised to the level 
of the umbilicus. 

Causes of elevation of the uterus may be classified under two gen- 
eral heads, namely, swellings below the uterus crowding it upward, 
or tumors and adhesions making upward traction upon the uterus. 

Swellings beneath the uterus and crowding the uterus upward 
are tumors of the cervix, vagina, rectum, haematocele, and hsemato- 
colpos. Adhesions binding the fundus to the abdominal wall may 
develop during pregnancy and the puerperium, leaving the uterus 
in elevation after the puerperium. Plate XXIV., Fig. 2, represents 



220 SPECIAL DIAGNOSIS 

the uterus suspended from the abdominal wall in an elevated position. 
A Csesarean section had been performed, and subsequently adhesions 
developed between the scar in the abdomen and that of the uterus. 

Fig. 140 represents a subperitoneal fibroid attached to the fundus 
and growing into the abdominal cavity. In this case either the 
pedicle must elongate or the uterus will be drawn upward, since 
the tumor, when it can no longer be accommodated in the pelvis, 
rises into the abdominal cavity. 

Tumors of the ovary with short pedicles may operate similarly. 
The vagina will be found greatly elongated and the cervix may 
not be within reach of the examining finger. 

TORSION OF THE UTERUS. 

In torsion of the uterus the organ is twisted upon its long axis. 
This displacement rarely exists singly, but is generally associated 
with anteposition, lateral position, or elevation. Within perfectly 
normal limits the uterus is slightly turned upon its long axis, due 
to a shortening of the broad ligament, which runs outward and 
slightly backward. 

Causes of torsion may be traction on the one hand or pressure on 
the other. Adhesions running from the side of the uterus back- 
ward or forward may turn the uterus upon its long axis, as will 
also pressure made upon the side of the uterus by tumor formations. 

Fig. 72 represents a pedunculated ovarian tumor lying in the 
abdominal cavity. The tumor has been turned upon its long axis, 
and with it the uterus has become twisted. It is even possible for 
the uterus to be severed by the twisting. The blood supply to the 
uterus may be shut off completely and cause gangrene, or partially 
and result in atrophy. Menstrual and intermenstrual secretions 
may be pent up in the uterus above the point of torsion. 

As a rule, the displacement is not discovered until an exploratory 
incision is made to remove the cause. 

PROLAPSUS UTERI. 

As suggested by Berry Hart, prolapsus uteri should be considered 
under the head of displacement of the pelvic floor. The displace- 
ment should be regarded as a hernia of the uterus, adnexa, bladder. 



PLATE XXV. 



FIG. 1 




Anteposition of tine uterus. A retrouterine haematoeele fills the 
eul-de-sae of Douglas and the space between the uterus and. sacrum. 
The uterus is crowded forward. 

FIG. 2, 




Anteposition. The loaded rectum crowds the uterus forward into 
anteposition when the bladder is empty. The cul-de-sac of Douglas 
is almost obliterated. When the rectum is empty the uterus will fall 
back into the normal position. 



PLATE XXVI. 



FIG. 




Primary prolapse of the uterus. The uterus lies wholly outside 
the vulva. The vaginal "walls are completely inverted; the cervix is 
not elongated. 

FIO. 2. 




Secondary descent of the ucerus. The uterus is retroverted and 
lies on a plane lower than normal. The cervix does not extend to 
the vulvar outlet. The anterior vaginal -wall is prolapsed and the 
posterior vaginal wall is partially inverted. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 



221 



rectum, and vagina. While the author is in accord with this view, 
it is thought best to consider the subject along with other displace- 
ments of the uterus, as is the custom with most text-books. Web- 
ster, in his text-book on Diseases of Women, holds that prolapsus 
of the uterus, vagina, urethra, and bladder is the result of failure 
on the part of the fascial and other tissues supporting these organs 



Fig. 72 




Torsion of the uterus caused by twisting of the pedicle of an ovarian cyst. 



between the bony walls of the pelvis to resist intra-abdominal 
pressure and gravity. If the power of resistance is weakened, or 
the intra-abdominal pressure and weight of the uterus are increased, 
or if both factors co-operate, prolapsus will occur. Webster takes 
exception to the view of Hart, who regards the perineum as a fixed 
segment for the support of the uterus, and of Thomas, who holds 
that the perineum is a supporting wedge. By anatomical dissec- 



222 



SPECIAL DIAGNOSIS 



tions Webster has demonstrated that the pelvic fascia and not the 
perineum and levator ani muscle is the real support. 

The various fascial tissues which meet in the perineum and give 
support to the pelvic viscera are: 1. The anterior and posterior 
triangular ligaments. 2. The visceral layer of the rectovaginal 
fascia. 3. The anal fascia. 4. The deep superficial fascia. Web- 



FiG. 73 




Complete laceration of the perineum with cystocele. C, divided ends of caruncular ring; 
Sph, divided ends of the sphincter. The loss of the pelvic floor and the sagging of the 
anterior waU of the vagina precede the descent of the uterus. 

ster holds that the perineal muscles are of little value as a support 
compared to the pelvic fascia. 

In the absence of actual rupture of the fascia it is possible for 
stretching alone to so weaken the support that prolapsus will occur. 

Prolapsus uteri is a term implying not only a descent of the 
uterus, but also involvement of the bladder, rectum, vagina, and 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 223 

adnexa. Descent of the uterus may be checked at any point between 
the normal position and extreme prolapse. 

Nomenclature. With Webster, the author will speak of (1) 
descensus uteri, when the uterus and vaginal walls do not descend 
beyond the vulvar outlet, and (2) prolapsus uteri, when the uterus 
and vagina descend beyond the vulvar outlet. 



Fig. 74 




The divided ends of the caruncular ring in the figure are approximated by tenacula. In this 
manner the extent of the laceration is demonstrated. 

The posture of the patient most favorable to recognition of a 
downward displacement of the uterus is the erect (Fig. 7). In 
the recumbent position the uterus may resume in part or wholly 
the normal position. The erect position is awkward and embar- 
rassing, and for these reasons is seldom used. With the patient in 
the lithotomy position, the uterus may be manipulated in such a 
manner as to effectively demonstrate the degree of descensus. 



224 SPECIAL DIAGNOSIS 

Bimanual manipulation, and, if necessary, traction upon the cervix 
with a vulsellum forceps, will bring the uterus down to its maximum 
degree. Under normal conditions it is not possible to draw the 
vaginal portion of the cervix beyond the vulvar outlet. 

Anatomical Diagnosis. The diagnosis is almost wholly based 
upon the anatomical findings. It is at times possible to make a 
diagnosis from inspection alone. 

Inspection of the vulva may disclose the uterus and vaginal walls 
protruding from the vulvar outlet. In nearly all such cases the 
perineum is lacerated, and there may be a prolapsus of the mucous 
membranes of the urethra and rectum (Fig. 73). 

Displacement of the Vagina. Inasmuch as the uterus is seldom 
displaced downward without a primary or secondary involvement 
of the vagina, we will first consider descensus and prolapsus of the 
vagina. 

1. Descensus vaginae implies a downward displacement of the 
vagina to a point short of the vulvar outlet. Preceding the descent 
of the vaginal walls there is usually a relaxation or laceration of 
the pelvic floor. As a rule, the anterior wall of the vagina is first 
to descend; then follows the uterus as it is pulled upon by the 
sagging wall of the vagina, and, finally, the uterus in turn carries 
with it the posterior wall of the vagina. It is unusual for the ante- 
rior and posterior walls of the vagina to descend simultaneously 
and equally. Yet more unusual is the primary descent of the 
posterior vaginal wall. A limited degree of descensus vaginse may 
exist without displacing the uterus. The descent occurs from 
below upward; seldom from above downward (Fig. 74). 

2. Prolapsus vaginae implies a protrusion of the vaginal walls 
beyond the vulvar outlet, and is always associated with downward 
displacement of the uterus. In primary descent and prolapse of 
the uterus the vaginal walls are inverted from above downward, 
there being no pouching of the vaginal walls as in secondary pro- 
lapse of the uterus. The lower segment of the vaginal wall may 
prolapse, the upper segment invert, and the intervening one remain 
unchanged. The prolapsed anterior vaginal wall pouches into the 
vagina, dragging the bladder with it, and forming what is known 
as a cystocele. The bladder is intimately attached to the anterior 
wall of the vagina, so that it is quite impossible for the vagina to 
descend without carrying the bladder with it. The vaginal wall 



PLATE XXVII. 

FIG. 1. 




Secondary prolapsus uteri >A^itlT elongation of the cervix. Both, 
vaginal avails are completely inverted. The cervix protrudes from, 
the vulva. JSTeither the bladder nor the rectum are found in the pro- 
truding structures. 

FIG. 2. 




Complete inversion of the uterus. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 225 

loses its usual elasticity, becomes glistening, dry, and leathery. 
Decubitus ulcers may form and show little tendency to heal. Between 
the posterior wall of the vagina and the rectum there is not that 
intimate attachment found between the bladder and vagina — a fact 
which explains why, in prolapse of the posterior vaginal wall, the 
rectum does not always descend with the vagina (rectocele). 

Descensus and prolapsus vaginae are recognized by inspection and 
palpation of the vagina. Holding the labia apart the vaginal pouch 
with its transverse folds is seen to bulge into the introitus. Inver- 
sion of the vagina is recognized by a corresponding shortening of 
the vaginal wall, together with a descent of the uterus. 

Displacements of the Uterus. After inspection and palpation 
of the vulva and vagina, the position of the uterus is to be deter- 
mined. The vaginal walls may be prolapsed to an unusual degree 
without altering the position of the uterus, though this is rare. 
Having observed a prolapse of the vagina we expect to find a sec- 
ondary descent of the uterus. The descent of the uterus may be 
either primary or secondary. 

1. Primary descent and prolapse of the uterus are the result of 
relaxed uterine supports, of added weight to the uterus, or of in- 
crease in the intra-abdominal pressure. As the uterus descends 
the anterior and posterior walls of the vagina become inverted from 
above downward, and near the outlet of the vagina the walls are 
relaxed. In exaggerated cases the vaginal walls may be completely 
inverted, thereby perm'^ting the uterus to protrude beyond the 
vulvar outlet. 

2. Secondary descent lii prolapse of the uterus follow upon a 
primary prolapse of the vr.ginal walls. As the walls of the vagina 
descend, traction is made uj. .m the uterus at the point of attachment 
of the vagina. If the supports of the uterus offer little or no resist- 
ance, the walls of the vagina, assisted by gravity and intra-abdomi- 
nal pressure, will bring about a descent of the uterus. If, however, 
the normal supports of the uterus, assisted by adhesions and new- 
growths, retard the descent of the uterus, there will result an elonga- 
tion of the cervix in its supravaginal portion. Furthermore, since 
the anterior wall of the vagina is first to prolapse, the anterior lip 
of the cervix will be elongated to a greater degree than will the 
posterior lip. If there is a simultaneous prolapse of both vaginal 
walls, the two lips of the cervix will be equally elongated. Hence, 

15 



226 SPECIAL DIAGNOSIS 

it is that in secondary prolapse of the uterus there is usually an 
elongation of the cervix, while in primary prolapse there is no such 
change. 

In complete prolapsus uteri, with inversion of both walls of the 
vagina, the cervix having been previously elongated, will retract 
more or less and may be materially shortened. The direction of 
the long axis of the uterus varies with the descent. The usual 
position in descensus uteri, when the uterus lies in the pelvis, is 
that of retroversion, and this position is exaggerated as the uterus 
descends. 

The adnexoB are drawn down by the uterus, and in complete pro- 
lapsus are found in a funnel-like depression formed of peritoneum. 

The bladder is so intimately connected with the anterior vaginal 
wall and cervix that it must necessarily share in the displacement 
of the uterus. As the anterior wall of the vagina pouches it drags 
upon the base of the bladder. In this manner a cystocele is formed 
which, in complete prolapse of the vagina, may include the greater 
portion of the bladder, causing it to protrude from the vulvar orifice. 
The exact limitations of a cystocele are determined by the catheter 
or sound in the latter. 

When the bladder is distended the cystic mass is felt and seen to 
protrude into the vagina, and its outlines are usually determined by 
inspection. 

The rectum is more loosely connected with the vaginal wall than 
is the bladder. The loose connective tissue may permit of a complete 
prolapse of the posterior wall of the vagina without displacing the 
rectum. More often there is a pouching forward of the rectum into 
the vaginal pouch (rectocele). By direct palpation through the 
rectum the location and extent of the rectocele are determined. 

The anatomical changes occurring in the prolapsed tissues are 
largely the result of disturbance in circulation, of exposure to the 
influence of air and of friction of the thighs. There is first conges- 
tion and oedematous infiltration, and this is followed by induration 
(hyperplasia) of the tissues. Decubitus ulcers, slow in healing, 
may form on exposed surfaces. Where the lips of the cervix are 
retracted, the exposed mucous membrane of the cervix may be 
transformed into stratified epithelium. 

Clinical Diagnosis. The diagnosis of descensus and prolapsus 
uteri is seldom diflficult. It is very unusual to find a prolapsed 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 



227 



uterus in a nullipara. Beyea estimates that prolapsus uteri in 
nulliparae occurs in not more than 1 per cent, of all cases. He 
reported two cases and found sixty-two others in the literature. 

When upon physical examination the pelvic floor is found relaxed 
or lacerated, and there is also found a rectocele and vesicocele, it is 
highly probable that the uterus will be found more or less pro- 



FiG. 75 




Elongation of the cervix with prolapsus uteri. Traction made upon the cervix by a 
vulsellum forceps pulls the cervix two inches beyond the vulvar outlet. The body of the 
uterus lies within the pelvis, but at a lower level than normal. The depth of the uterine 
cavity measured by a sound is five inches. 



lapsed. A positive diagnosis can only be made by locating the 
fundus of the uterus in a bimanual examination. The patient 
being under ansesthesia, firm traction upon the cervix with the 
vulsella forceps will determine the exact extent of the displacement 
(Fig. 75) . The finding of the cervix at a lower level than is normal 
will not suffice for a diagnosis. Such a finding is not seldom due 
to an elongation of the cervix, either with or without a descent of 



228 



SPECIAL DIAGNOSIS 



the uterus. Without having located the fundus it cannot be said 
that the uterus, as a whole, has descended. By a rectal examina- 
tion it is often possible to locate the point of juncture of the cervix 
and uterine body, and estimate with some degree of accuracy the 
length of the cervix. Measuring the depth of the uterus by the 
sound will give exact information. 



Fig. 76 




Prolapsus uteri. The external os is lacerated and eroded. On the side of the prolapsed 
uterus is a decubitus ulcer. (Case of J. C. Webster's.) 



It is more difficult to determine whether it is the supravaginal or 
infra vaginal portion of the cervix that is elongated. This is ascer- 
tained by noting the depth of the vault of the vagina. If decreased 
in depth, the supravaginal portion of the cervix is elongated; if it 
remains at the normal level, the infravaginal portion of the cervix 
is elongated. Both the infravaginal and supravaginal portions of 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 229 

the cervix may be increased in length, in which event there will be 
little change in the depth of the vault of the vagina. 

When the uterus is completely prolapsed it is possible to approx- 
imate the hands over and above the body of the uterus, having 
merely the vaginal walls and bladder between the fingers. By 
so doing it is possible to absolutely exclude all other conditions 
(Fig. 77). 

Can the displacement of the vagina and uterus he corrected? This 
question will naturally arise before the diagnosis is complete. An 

Fig. 77 




Bimanual palpation of the prolapsed uterus. 

attempt to replace the uterus may be made without anaesthesia, but 
where there is much tenderness or where great diflaculty is encoun- 
tered an anaesthetic should be given. Among hindrances to the 
replacement of the uterus may be mentioned pelvic tumors, adhe- 
sions, inflammatory exudates, and swelling from oedema and indura- 
tion of the uterus and vagina. 

While the clinical symptoms cannot be relied upon in the diag- 



230 



SPECIAL DIAGNOSIS 



nosis of prolapsus uteri, they are fairly constant and deserve con- 
sideration. 

Backache is the most common complaint, but is more often due 
to diseases of the adnexse and to inflammatory exudates complicating 
prolapsus. 

Feeling of weight, ^pressure, and traction is to be accounted for 
by the increased size of the uterus, by pressure upon neighboring 



Fig. 78 




Prolapse of the third degree. Uterus protruding through the vulva. Sounds demonstrate 
the bladder to be in complete descent with the uterus. (Schaffer.) 



structures, and by traction upon adhesions and the natural supports 
of the uterus. 

Leucorrhoea and menorrhagia are the results of passive congestion 
of the uterus, which in turn is the result of the displacement. 

Sterility is due to mechanical hindrances and to complicating 
lesions in the uterus and adnexse. Pregnancy in a prolapsed uterus 
will either terminate spontaneously or go on to full term. Abortion 
is most likely to occur about the fourth month, when the pregnant 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 231 

uterus can no longer be accommodated in the limited space of the 
pelvis. If, however, the uterus does rise into the abdominal cavity, 
the prolapsus is relieved for the period of pregnancy. Involution 
in the puerperium is likely to be retarded, and the lochial discharge 
may remain bloody an unusually long time. 

Disturbances of the bladder junctions are almost constant, and are 
explained by pressure upon the bladder and the displacement of the 
bladder and urethra. Retention of the urine is possible even to 
the point of rupture. Cystitis may develop. 

The rectal junctions are generally disturbed, though not to the 
extent and frequency found in the case of the bladder. Constipa- 
tion, rectal tenesmus, and hemorrhoids are the result of pressure 
made upon the rectum by the prolapsed uterus. 

Differential Diagnosis. Prolapsus uteri is most often confused 
with an elongated cervix. The differential diagnosis has been 
considered in a previous paragraph. The vaginal portion of the 
cervix may be so enormously enlarged as to resemble a prolapsed 
uterus. 

Complete prolapsus uteri with atresia of the cervix may be mis- 
taken for an inverted uterus. The finding of the fundus will clear 
up the diagnosis. 

A large cyst of the vagina may protrude from the vulva, and on 
superficial examination be mistaken for a prolapsed uterus. Such 
cysts do not lie in the median line; they fluctuate, and are covered 
with thin mucous membrane. A rectoabdominal examination, 
under ansesthesia if necessary, will enable the examiner to locate 
the body of the uterus in its normal position. 

A pedunculated submucous fibroid protruding into the vagina, 
or a pedunculated fibroid of the cervix, may be mistaken for a 
prolapsed uterus. The absence of the external os in the advancing 
body, the finding of the fundus within the pelvis at its normal level, 
and the passage of a sound into the uterine cavity will clear the 
diagnosis. 

INVERSION OF THE UTERUS. 

Inversion of the uterus is the partial or complete turning inside 
out of the organ. 

Etiology and Mechanism. Puerperal inversion is by far the 
most common form. It occurs in the puerperium nine times more 



232 



SPECIAL DIAGNOSIS 



frequently than at any other time. Traction upon the cord in 
retained placentae is the usual way in which the accident occurs 
(Figs. 79 and 80). 

In 192,000 labors at the Rotunda Hospital, in Dublin, but one 
case is reported. Kehrer's estimate is 1 in 2000 labors. The one 
essential condition in all inversions of the uterus is atony of the 
musculature in some part of the uterine body. Predisposing factors 
to atony of the uterus are frequent childbearing, protracted labors, 



Fig. 79 



Fig. 80 




Beginning inversion of uterus, placenta 
attached. (Modified from Ribemont-Des- 
saignes and Lepage.) 




Cup-shaped depression of fundus. (Modi- 
fied from Ribemont - Dessaignes and Le- 
page.) 



hydramnios, twin pregnancy, precipitate labors, and repeated mis- 
carriages. With these conditions operating to fatigue and relax 
the uterine musculature, it only needs such precedures as traction 
upon the cord and compression of the fundus to effect an inversion. 
Spontaneous inversion may occur during or immediately follow- 
ing the third stage of labor, the mechanism being not unlike that 
of intussusception of the bowels. Of 100 cases of inversion of the 
uterus collected by Beckmann, 54 were spontaneous, 21 were 
directly caused by traction upon the cord, and 25 were from un- 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 233 

known causes. Of the spontaneous cases many were accounted 
for by the presence of short cords or cords twisted about the neck 
of the foetus. Immediately upon expulsion of the child a vacuum 
is created in the uterus, and, if in addition there is atony of the 
fundus, the intra-abdominal pressure may produce an inversion. 

It is difficult to account for inversions occurring late in the puer- 
perium. Those due to tumor formations in the body of the uterus 
are of rare occurrence. Such tumors operate first by weakening 
the uterine wall, and, second, by making traction upon the atonic 
area. Pedunculated fibroids arising from the fundus are forced 
through the cervix into the vagina by the contractions of the uterus. 
If there is a relaxation at their point of insertion this action may 
cause an inversion of the fundus. 

Therefore, we may divide inversion of the uterus from an etio- 
logical point of view into: 

1. Puerperal inversion. 

2. Inversion due to tumor formations. 

Olshausen reported a case of inversion in a girl, aged eighteen 
years. There was no assignable cause. This is one of the very 
few cases of spontaneous inversion occurring independent of labor 
and new-growths. 

Anatomical Diagnosis. Three grades of inversion are recog- 
nized : 

1. Where the fundus lies within the uterine cavity. 

2. Where the fundus lies within the vagina. 

3. Where the entire uterus protrudes from the vulva. 

In the depression formed by the inverted fundus are found the 
tubes, ovarian ligaments, and part of the round and broad ligaments. 
The ovaries are rarely found within the depression. The mucosa 
covering that portion of the inverted fundus lying within the vagina 
and external to the vulva undergoes retrogressive changes. In the 
beginning there is marked congestion; later erosions and true ulcers 
may develop, and the covering of columnar epithelium may be 
converted into many layers of stratified squamous cells. 

Sloughing and gangrene of the inverted uterus may result from 
interference with the circulation. 

Following the congestion of the inverted body is an enlargement 
of the uterus from hyperplasia, which, when of long standing and 
far advanced, may prevent replacement of the inverted fundus. 



234 



SPECIAL DIAGNOSIS 



From the tubes infections may travel to the ovary, pelvic connec- 
tive tissue, and peritoneum. Adhesions may bind together the 
tubes, ovaries, and coils of intestines within the funnel-shaped 
depression. 

Clinical Diagnosis. The diagnosis can only be made with cer- 
tainty by a physical examination. Subjective signs awaken no 



Fig. 81 



Fig. 82 





Complete inversion of uterus. (Modified from 
Eibemont-Dessaignes and Lepage.) 



Partial inversion of uterus. (Modified from 
Ribemont-Dessaignes and Lepage.) 

more than a suspicion of the 
accident. The inversion may 
take place suddenly or slowly, 
and is referred to as acute or 
chronic. There is a sensation 

of something giving way in the pelvis, and this is immediately 
followed by hemorrhage. The loss of blood may result fatally, or 
may be limited in amount and merely prolong the menstrual flow. 
In the intervals of the bloody flow there is a profuse serous or 
seropurulent discharge. Partial inversion may occasion no symp- 
toms and may escape notice. The functions of the bowel and 
bladder are disturbed, and general physical exhaustion follows. 

Under favorable conditions for making a bimanual examination 
it is possible to demonstrate by the hand over the abdomen or in 
the rectum the absence of the fundus and in its place a funnel- 
shaped depression. By the fingers in the vagina the inverted fundus 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 235 

Fig. 83 



The inverted uterus U, lying in the vagina V, is cut open to show the peritoneal sac, which 
does not contain the ovaries 0. Bristles are passed into the uterine orifice of the tubes. 
b, broad ligament; r, r, round ligament; T, T, tubes. (Hart and Barbour.) 

Fig. 84 Fig. 85 





Partial inversion of the uterus; the inverted The uterus is divided by a septum from 

fundus lies within the cavity of the uterus. the fundus to the internal os. 



236 



SPECIAL DIAGNOSIS 



Fig. 86 



is felt bulging into the cavity of the uterus, into the vagina, or 
beyond the vulvar outlet. A sound placed within the bladder 
may assist as a guide in the bimanual examination. The finger in 
the rectum may be made to meet the sound in the bladder or the 
hand on the abdomen, thereby demonstrating the absence of the 
uterine body. In the protruding fundus are seen the tubal openings, 
there being no external os. Where the inversion is not complete 
the cervix may form a contraction ring about the presenting fundus. 
By drawing upon the fundus with one hand, the fingers of the 
other hand in the rectum may be hooked over the margin of the 
funnel-shaped depression. 

A sound passed into the vagina and between the protruding 
fundus and cervix will extend a limited distance and equally so 

around the entire circumference. In 
puerperal inversion the free, rounded, 
bleeding mass, with its soft, shaggy sur- 
face protruding into the vagina, should 
suffice for a diagnosis when associated 
with the disappearance of the usual ab- 
dominal tumor. 

Differential Diagnosis. Pedunculated 
fibroids and polyps lying within the va- 
gina are to be differentiated from inver- 
sion of the second degree by locating the 
fundus of the uterus wdthin the pelvis by 
a rectoabdominal examination; second, 
by passing a sound into the uterus 
and finding the cavity of normal or increased depth ; third, by 
the absence of tubal openings in the protruding mass. 

Submucous polyps and fibroids lying within the cavity of the uterus 
show by the passage of the sound an increase in the depth of the 
cavity of the uterus, and by a rectoabdominal or by a vagino- 
abdominal examination the fundus is located within the pelvis. 
Care must be taken in passing the sound that the growth does not 
obstruct the passage of the instrument, giving the impression that 
the uterine cavity is shortened. 

A partially divided uterus with a depression in the fundus may, in 
the passage of the sound and palpation of the fundus, give the 
impression of a partial inversion. (See Figs. 84 and 85.) 




Complete inversion of the uterus. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 237 

Submucous fibroids with partial inversion may not be recognized 
from a simple inversion before operating for the removal of the 
tumor. 

Prolapsus uteri is distinguished from an inversion by the oblitera- 
tion of the vaginal fornices, by finding the external os at the bottom 

Fig. 87 Fig. 88 





Fig. 88. — Cervical polyp, possible to mistake for an inverted fundus. The differential 
diagnosis is made by passing a sound into the uterine cavity and by locating the fundus in a 
bimanual examination. 

Fig. 89. — Cervical polyp with atresia of the cervix. A sound cannot be passed into the 
uterus, but the fundus is located within the pelvis by a conjoined examination. 

of the protruding mass, and by the absence of a cup-shaped depres- 
sion in the fundus. A sound passed through the cervix will sink 
to the depth of the normal uterine cavity. 



ANTEVERSION OF THE UTERUS. 

No sharp distinction can be drawn between a physiological and 
a pathological anteversion of the uterus. Within perfectly normal 
limits the long axis of the uterus is turned forward upon an imag- 
inary transverse axis. A permanent exaggeration of this condition 
may be regarded as pathological. 



238 SPECIAL DIAGNOSIS 

Etiology. An exaggerated temporary and physiological antever- 
sion is found when the rectum is distended and the bladder empty, 
and also in the early months of pregnancy. 

Chronic metritis is the most common cause of pathological ante- 
version. The increased weight of the uterus causes the body to fall 
forward, the cervix to turn backward. 

Contraction of the uterosacral ligaments from a retrouterine 
cellulitis will draw the cervix backward and tilt the body forward. 
Here retroposition is commonly associated with ante version. 

More rarely adhesions bind the anterior surface of the uterus to 
the bladder or abdominal wall. 

Any swelling behind the uterus may exert pressure upon the 
uterus in a manner that will produce an anteversion. 

A mural fibroid located in the anterior wall of the uterus may 
cause the uterus to revolve forward by increasing the weight of 
the body. 

The diagnosis is made by a conjoined examination. The cervix 
points backward, or backward and upward, ancf the body is pal- 
pated through the anterior wall of the vagina lying well upon the 
bladder and behind the symphysis. So extreme may the version 
be that the body may press down upon the anterior vault of the 
vagina, forming a rounded swelling not unlike a cystocele in appear- 
ance. In such a case the external os will be difficult to touch with 
the examining finger. 

When for any reason the position of the uterus cannot be located 
by a conjoined examination, the sound will determine the direction 
of the uterine canal. 

There are no characteristic symptoms. Frequent urination is 
the most constant complaint. Where other symptoms exist they 
are usually caused by complications rather than by simple displace- 
ment. 

After locating the uterus in anteversion, the next step is to deter- 
mine the cause of the displacement. (See Plate XXVIII., Fig. 1.) 

ANTEFLEXION OF THE UTERUS. 

As with anteversion, so with anteflexion of the uterus; it is not 
possible to draw a line between the normal and the abnormal posi- 
tion. In anteflexion the uterus is bent forward upon its long axis. 



PLATE XXVIII, 

FIO 1. 




Anteversion of the "uterus. The cervix points baelcvvarci to the 
saerum, the body forward, upon the bladder and anterior vaginal 
■wall. The long axis of the uterus is straight. 

FIG. 2. 




Anteflexion of the uterus. The uterus is bent forward upon its 
long axis. There is very little alteration from the normal A sub 
peritoneal fibroid on the anterior wall forms a sharp angle, resem- 
bling an anteflexed uterus. ^^ ^ > 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 239 

The cervix is directed downward and forward and the body for- 
ward, thereby forming an angle at the junction of the body and 
cervix. 

In an abdominovaginal examination the body should be engaged 
betwen the two hands and the angle of flexion felt by the finger 
within the vagina. When the anteflexed uterus lies in retroposi- 
tion, the flexion may be best found by the finger high in the rectum, 
feeling the angle upon the posterior surface of the uterus as the 
body bends forward upon the cervix. This examination will be 
materially facilitated by an anaesthetic. The sound will be of 
special service when it is otherwise impossible to outline the uterus 
because of tumors and inflammatory exudates encroaching upon it. 
The size, shape, and consistency of the uterus will usually serve to 
distinguish the uterus from all such swellings. 

Having determined the position of the uterus, and before any 
treatment is proposed, it is essential to clearly define the cause of 
the displacement. Is the uterus fixed or free and movable? If 
free and movable the fault may be a hypoplasia of the uterine wall 
at the point of flexion, and is, in all probability, a congenital defect. 
Here the uterus is very often found to be undersized (hypoplasia). 
If the uterus is restricted in its movements, the cause may be a 
congenital or an acquired shortening of the uterosacral ligaments; 
new-formations and exudates lying behind the body of the uterus 
and crowding it forward; less frequently an increase in the weight 
of the body of the uterus. 

An intramural fibroid lying in the anterior wall of the uterus 
may form an angle with the cervix, which to the examining finger 
resembles an anteflexion. The form and consistency of the tumor, 
together with the passage of the sound, will locate the uterus apart 
from the tumor. (See Plate XXVIII., Fig. 2.) 

Anteversion and anteflexion are frequently combined. 

The subjective signs of anteflexion of the uterus are frequent 
urination, dysmenorrhoea, and sterility, though these are by no 
means constant. It is not likely, as is generally believed, that dys- 
menorrhoea is due to obstruction to the outflow of the menstrual 
blood. The angle of flexion can scarcely be so acute as to interfere 
with the flow of blood. The explanation probably lies in the accom- 
panying inflammatory lesions in and about the uterus and possibly 
also in spasmodic contractions of the internal os. Sterility can 



240 SPECIAL DIAGNOSIS 

probably be accounted for by the accompanying Inflammatory 
lesions rather than by the flexion. When the cervix points well 
forward the spermatozoa cannot so readily gain access to the cervix 
as when directed toward the posterior wall of the vagina. 

RETROVERSIOFLEXION OF THE UTERUS. 

In retroversion the long axis of the uterus revolves backward 
upon an imaginary transverse axis. Such a position is physiological 
when the bladder is full and the rectum empty, the patient lying on 
her back. 

In retroflexion the uterus is bent backward upon its long axis. 
There is no physiological retroflexion of the uterus. 

The two positions, retroversion and retroflexion, are caused by 
the same factors, and are commonly combined, retroflexion follow- 
ing retroversion. Because of their intimate association they will be 
discussed together. In virgins and in chronic metritis the uterus 
is seldom flexed, but remains in retroversion rather than in retro- 
versioflexion. (See Plate XXIX., Fig. 2.) 

Etiology. Schultze gives five causes for retro versioflexion, namely : 

1. Failure in development. 

2. Fixation of the portiovaginalis on the anterior pelvic wall. 

3. Unilateral posterior fixation of the cervix. 

4. Shortening of the posterior or lengthening of the anterior 
uterine wall. 

5. Relaxation of the supporting uterine ligaments and muscles. 

1. Among the developmental failures contributing to retro versio- 
flexion may be mentioned the proportionately long cervix and short 
vagina. In the presence of such a condition an increase in the 
abdominal tension or a sudden fall would be suflacient cause for a 
retro versioflexion . 

2. Fixation of the portiovaginalis upon the anterior pelvic wall 
may be the result of cicatricial contraction of the anterior wall of 
the vagina. Hence it is that retro versioflexion is frequently found 
in large vesicovaginal fistulse and in stenosis of the vagina. 

3. Unilateral posterior fixation of the cervix occurs in about 6 per 
cent, of all cases of retroversioflexion (Schultze). The cause is 
retrouterine cellulitis or peritonitis, more often confined to one 
sacrouterine ligament. 



PLATE XXIX, 

FIG 1. 




Retroposition and. Retroversion of the Uterus. Th.e distended bladder 
crowds the uterus backward into retroversion and retroposition. 
>A^hen the bladder is empty the uterus "will fall forward into antever- 
sion and anteposition. 

FIG 2. 




Retroposition and Retroversion of the Uterus, with Fixation. Peri- 
toneal adhesions bind the posterior surface of the uterus to the sacruni 
and rectum, holding the uterus firmly in retroversion and retroposition. 



PLATE XXX. 

FIO. 1. 




Retroversioflexion of the Uterus, witli. Adhesions. The body is 
adherent in the eu.l-de-sae. The long axis of the uterus is bent back- 
ward and the cervix is directed downward. 



FIC 2. 




Ineaxcerated Subperitoneal Fibroid on the Posterior Wall of the 
Uterus. The fibroid may be confounded with the body of the uterus. 
The uterus lies in retroversioflexion. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 241 

4. Shortening of the posterior wall or lengthening of the anterior 
wall of the uterus is a rare finding. 

5. Relaxation of the supporting uterine ligaments and muscles is 
by far the most frequent cause of retro versioflexion. When these 
supports are weakened the long axis of the uterus first revolves 
backward upon an imaginary transverse axis (retroversion), and 
later, through the force of intra-abdominal pressure, the long axis 
of the uterus is bent upon itself (retroflexion). The stretching and 
tearing of childbirth largely account for the relaxation of the sup- 
porting uterine ligaments and muscles. Retro versioflexion due to 
violent exertion or to a fall is difficult to establish though not im- 
possible. The cause of retrodisplacements of the uterus in the 
nullipara is difficult of explanation in the absence of swellings 
crowding the uterus backward or adhesions pulling it backward. 
Tight lacing and habitual overfilling of the bladder will account 
for a limited number of these cases. Not a few are congenital, as 
is shown by anatomical dissections of infants. Salin found as many 
nulliparae as multiparse with retro versioflexion. He estimates the 
frequency of this displacement in all cases at 18 per cent. 

Heredity probably plays no role, though mother and daughters 
are often similarly affected. 

During the puerperium, when the uterus is large and soft, the 
ligaments relaxed, and the patient lying on her back, all the con- 
ditions favoring retroversion are present. This retroversion may 
go on to the development of a retroflexion through the influence of 
intra-abdominal pressure. Rising too early from childbed favors 
malpositions, as well as does lying too long in the dorsal position. 
It is for the purpose of avoiding such malpositions that the patient 
is instructed to lie in bed until the uterus and ligaments are well 
contracted and retracted. It is obvious that the patient should not 
lie constantly in the dorsal position, but should from time to time 
assume the knee-chest position, or at least lie upon the side or face. 

As to the frequency of retrodeviations of the uterus, the statistics 
of Winckel, Lohlen, and Sanger show an average of 17.74 per cent, 
of all gynecological cases (Reed). 

Anatomical Diagnosis. When the cervix is crowded forward 
the anterior vaginal wall is relaxed, while the posterior wall is taut. 
In retroversion the cervix points forward or forward and upward, 
sometimes lying above the level of the symphysis. In retroflexion 

16 



242 SPECIAL DIAGNOSIS 

the cervix is directed downward and backward. When the body 
of the uterus Hes in the hollow of the sacrum the cervix must 
necessarily lie well forward to the symphysis. If, as is often found, 
retro versioflexion is associated with descensus uteri, the cervix 
may be elongated. If a bilateral laceration of the cervix is present 
the vaginal walls will draw the lips of the cervix wide apart, expos- 
ing the mucous membrane of the cervical canal. 

In retroversion the body of the uterus approaches the promon- 
tory, and may be found low in the pouch of Douglas. There is no 
angle of flexion between the body and cervix. The cervix and 
body lie in a straight line. In retroflexion the body may form an 
acute angle with the cervix. Often the uterus in retroversioflexion 
inclines to the left or right, and in extreme cases is almost invariably 
more or less prolapsed. 

(Edema and passive congestion, leading to hyperplasia of the 
endometrium and myometrium, are the almost inevitable results of 
the displacement. We, therefore, find endometritis and metritis 
associated with long-standing retroversioflexion. Not seldom do 
diffuse peritoneal adhesions bind the uterus, tubes, ovaries, and 
bowel together. The tubes and ovaries lie at a low level and suffer 
congestion and hyperplastic changes, leading to catarrhal salpingitis, 
chronic ovaritis, and cystic degeneration of the ovaries. 

The bladder may be directly pressed upon by the cervix, causing 
frequent urination. In the retroflexed gravid uterus there may be 
retention of urine. , 

The rectum is compressed, and may be obstructed by the body 
of the uterus. 

Clinical Diagnosis. The great number of cases of retroversio- 
flexion in which no symptoms are present speaks for the unrelia- 
bility of subjective signs. Wormser asserts that uncomplicated 
cases of retroflexion in healthy women produce no symptoms. 
When disturbances exist some local complication must be present, 
or there is a deranged nervous system. E. Schroeder reports 411 
cases examined, in which 188 (28.7 per cent.) had retroversio- 
flexion of the uterus, and of this number 25 per cent, were free 
from symptoms. He reasons that uncomplicated retrodisplace- 
ments of the uterus cause no symptoms; that those so frequently 
ascribed to such displacements are due to complicating lesions. 
Yet how often do we find extensive adhesions fixing the uterus in 



PLATE XXXI. 

FIG. 1. 




Retroposition of the Uterus. The uterus is drawn backward, into 
retroposition by peritoneal bands of adhesions extending from the 
supravaginal portion of the cervix to the sacrum. 



FIG. 2. 




Elevatiouteri follo\ving a Ventrosuspension of the Uterus. Adhe- 
sions unite the fundus of the uterus to the abdonninal wall and 
retain the uterus in an elevated position. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 243 

malpositions without causing either local or general disturbances. 
On the other hand, the disappearance of local disturbances imme- 
diately upon the correction of a non-complicated displacement can- 
not be wholly explained on the ground of suggestive treatment. 

1. Menstrual irregulaxities are common, and usually take the form 
of an increase in the menstrual flow. This is explained by the 
passive congestion of the uterus. Extreme ansemia may result 
from the loss of menstrual blood. The menopause may be delayed 
because of the passive congestion. During pregnancy and the 
period of lactation occasional hemorrhage can be similarly accounted 
for. 

2. The habit of abortion is in many instances explained by the 
uterine congestion. 

3. Leucorrhoea in the form of a hypersecretion of the glands of 
the uterus is almost invariably present, and is caused by passive 
congestion of the uterus. 

The congested uterus is a favorable nidus for micro-organisms, 
and so it happens that the glandular secretion is often mixed with 
pus and micro-organisms. 

4. Dysmenonhoea of the so-called congestive type is seldom 
absent. It is not probable that the menstrual flow is obstructed 
at the point of flexion. The occurrence of pain is probably ex- 
plained by the addition of the menstrual congestion to the already 
engorged uterus. 

5. Sterility is a not uncommon result of retro versioflexion of the 
uterus. The incapacity for childbearing should be credited not so 
much, if at all, to the flexion of the uterus as to the inaccessibility 
of the cervix to spermatozoa when crowded forward and upward, 
to endometritis, and to complicating lesions in the adnexa and 
perimetrium. 

6. Disturbances of the functions of the bladder and rectum are 
accounted for by direct pressure. 

7. Pain in the pelvis referred to the groin, thighs, and back is 
the most constant of the subjective signs, but cannot be regarded 
as of great importance from a diagnostic standpoint, because pain 
is not an invariable symptom and does not differ from that caused 
by other lesions of the pelvic viscera. Backache is a common com- 
plaint, and is referred to the coccyx (coccygodynia), to the lumbar 
region, or to the area between the scapulae; rarely to the cervical 



244 SPECIAL DIAGNOSIS 

region. The absence of pain in many extreme retrodisplacements 
of the uterus suggests a doubt that the displaced uterus 'per se is 
the cause of the pain. Certainly the accompanying lesions, such 
as ovaritis, salpingitis, and perimetritis, account in large measure 
for the pain. Pressure upon the sacral plexus of nerves is the 
explanation of the pain referred to the thighs, and since the uterus 
is rarely found in the median line these referred pains in the lower 
extremities are for the most part unilateral. 

8. Reflex symptoms, such as headache, neuralgia, dyspepsia, hys- 
teria, and neurasthenia, are often attributed to the displacement, 
but it seems impossible to demonstrate such to be a fact with any 
degree of positiveness. 

It is clear that a diagnosis cannot be based upon the subjective 
signs. Too many cases exist in their absence, and the complaints 
of the patient are those found in almost any of the lesions of the 
pelvis. A physical examination is therefore required to establish a 
diagnosis. A diagnosis includes not only the location of the uterus, 
but also the condition of the adnexse and neighboring structures. 
Here, as in the diagnosis of all displacements of the uterus, it is 
first necessary to locate the uterus, and, second, to determine the 
underlying cause of the displacement and the existence of compli- 
cating lesions within the pelvis and abdominal cavity. 

In making a bimanual examination the position of the vaginal 
portion of the cervix may be an indication of the position of the 
uterine body. For example, if the cervix lies in its normal position, 
pointing downward and backward toward the second sacral vertebrae, 
the body must lie in the normal position or retroflexed; it would 
be impossible for a retroversion to exist with the cervix pointing 
downward and backward. If the cervix lies in front of its normal 
position and pointing directly downward, one of two positions is 
present, a retroflexion or an anteposition. It is sometimes possible 
to recognize a retroflexion in a simple vaginal palpation by feeling 
the angle of flexion through the posterior fornix. Where condi- 
tions are not favorable a positive diagnosis of the position of the 
uterus can only be made by a conjoined examination under anaes- 
thesia. 

A rectoabdominal or rectovaginoabdominal examination affords 
better means of palpating the uterus when lying far back against 
the rectum. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 245 

The use of the sound should be restricted, but it is occasionally 
called into service when a bimanual examination will not suffice. 

7^' the Uterus Fixed or Movable? First of all we must have clearly 
in mind what constitutes normal mobility of the uterus. It is not 
enough that the uterus should permit the usual excursions when 
manipulated, but it must return to its normal position when pressed 
out of place. Failing to do so constitutes a pathological condition. 

The fixity of the uterus is determined by the effort to replace it. 
Sensitiveness and thickness of the abdominal wall may render an 
anaesthetic necessary. 

The technique of replacing a uterus in retroversioflexion is briefly 
outlined as follows: 

The bladder and rectum are empty. The patient lies in the 
lithotomy position. One, and where possible without pain, two 
fingers are inserted into the posterior vaginal fornix, and moderate, 
steady pressure is made upon the uterine body in an upward and 
forward direction. The hand over the abdomen presses steadily in 
the effort to pass over and behind the fundus, as it is forced upward 
and forward by the fingers in the vagina. Sometimes the body will 
rotate forward by the finger pressing backward upon the cervix. 
With the middle finger in the rectum, it is possible to exercise more 
direct pressure upon the body of the uterus in extreme retroflexion. 
Traction upon the cervix by a tenaculum will bring the uterus 
more within reach of the fingers in the vagina and rectum. An 
anaesthetic is usually advisable. Formerly, in reposition of the 
uterus, a sound was advised, but the dangers of perforations are too 
great to justify its general use. Certain it is that the sound should 
not he used where the uterus is fixed. In replacing the uterus force 
must not be used for fear of tearing existing adhesions, causing 
hemorrhage, and injuring adherent viscera. 

Having determined the position of the uterus and the fact that 
it is not replaceable, it next becomes necessary to determine the 
cause of the inhibition. As possible causes may be mentioned 
adhesions and pelvic exudates, inflammatory contractions of the 
ligaments, and pelvic tumors. Peritonitic adhesions (peritonitis) 
for the most part arise from extension of infection through the 
tubes, and are most often found about the tubes and ovaries. Since 
infected tubes commonly lie in the cul-de-sac of Douglas, the sur- 
rounding adhesions may bind the uterus to the rectum in retrover- 



246 SPECIAL DIAGNOSIS 

sion or retroflexion. Peritoneal adhesions are recognized by their 
location on surfaces covered with peritoneum and by the ease with 
which they may be broken up as compared with parametritic adhe- 
sions. 

Parametritic adhesions correspond in location to the cellular tissue 
of the pelvis which is found between the layers of the broad liga- 
ment, underneath the pouch of Douglas, and to a limited extent in 
front of the uterus beneath the vesicouterine fold of peritoneum. 

Retroversioflexion may be brought about by adhesions in the 
cellular tissue of the vesicouterine space drawing the cervix forward 
and rotating the body backward — this, however, is quite unusual. 

Retrouterine parametritis, when involving only the supravaginal 
portion of the cervix, tends to produce an anteversion by drawing 
the cervix backward and rotating the body forward. In extreme 
cases the uterorectal fold of peritoneum may be crowded upward 
and permit the parametritic adhesions to adhere high up upon the 
posterior surface of the uterus, and by traction upon the body a 
retroversion is caused. Parametritic adhesions are thicker and 
firmer than they are in parimetritis. They are found on a lower 
level, are more accessible through the vagina, and are located where 
the cellular tissue of the pelvis is found. 

Pregnancy in a retroflexed uterus may prove a serious condition. 
No special difficulty is experienced in the first two months, but in 
the third and fourth months the uterus, no longer able to accom- 
modate itself to the small pelvis, is prevented from rising into the 
abdominal cavity. As a result pregnancy will be interrupted, or 
pressure symptoms will become increasingly severe and demand 
operative interference. On bimanual examination the large, soft, 
and elastic uterus may be found to bulge into the posterior vaginal 
fornix even to the introitus. The cervix is forced high behind the 
symphysis, and is directed forward or forward and downward. 
The soft cervix and softer lower uterine segment may be felt to 
connect at an angle with the large, rounded, soft, and elastic body 
of the uterus. Because of the great softening the uterine body 
may appear detached from the cervix, and in case the cervix is 
hypertrophied it may be mistaken for the entire uterus and the body 
may be thought to be a new-growth. 

Differential Diagnosis. Retroversioflexion is most often con- 
founded with retr opposition. In the latter the cervix lies in the 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 247 

posterior segment of the pelvis, while in retroversioflexion it lies 
anterior to the normal position. In both conditions the body of 
the uterus lies far back in the pelvis, but in the latter the long axis 
of the uterus is no longer in the normal line of direction. 

Anteflexion may be mistaken for retroversion. The cervix points 
in the same direction — forward and downward — and the body 
may be small, and therefore overlooked or mistaken for the supra- 
vaginal portion of the cervix. ' If on bimanual examination the 
body of the uterus cannot be located a sound may be passed. 

A retrouterine subperitoneal or interstitial fibroid may form an 
angle with the cervix that can be mistaken for the body flexed upon 
the cervix. The body of the uterus is recognized by its size, form, 
consistency, and direct relation to the cervix. Such a fibroid should 
present a circumscribed area of firmer consistency and produce an 
irregularity in the uterus. Where the bimanual examination will 
not suffice for a diagnosis, the uterine sound may be used. 

Swellings of the tubes and ovaries lying behind the uterus, retro- 
uterine hsematoma and hsematocele, and parametritic exudates are 
all to be differentiated from retroversioflexion by a consideration 
of the clinical history and by finding a mass behind the uterus that 
differs in size, form, and consistency from the uterus, and which, 
by the use of the sound, is found to be separate from the uterus. 
For further discussion, see respective chapters on these subjects. 

HERNIA OF THE UTERUS (HYSTEROCELE). 

Hernia of the uterus is of rare occurrence. The rupture usually 
occurs through the inguinal canal, less often through the crural 
ring. The only two recorded cases of crural hernia are those of 
Bowen and Duges. Fifteen cases of inguinal hernia of the uterus 
were collected by Kiistner; of these, eight were pregnant. The 
explanation of the development of the hernia is usually given as 
traction made upon the uterus by adhesions binding the hernial sac 
to the uterus and drawing the uterus within the sac. There is 
generally some associated anomaly in development. 

The diagnosis is made by palpation and by an exploratory incision. 

Hernia of the uterus through the linea alba may follow ventro- 
suspension. Plate IX. represents the hernia of a uterus in the 
fourth month of pregnancy. 



CHAPTEK XXIV. 

THE DIAGNOSIS OF DISEASES OF THE VULVA. 

Anomalies in Development. 

Vulvitis. 

Circulatory Disturbances. 

Atrophy (Kraurosis Vulvae). 

New-formations. 

Ulcers. 

Pruritus Vulv^. 

Hymen. ^ 

For a detailed description of the anatomy of the external genital 
organs, the reader is referred to text-books on gynecology and 
human anatomy. 

ANOMALIES IN THE DEVELOPMENT OF THE VULVA. 

Absence of the Vulva. This condition is very rare, and is, as 
a rule, associated with a congenital absence of the internal organs 
of generation. Absence of one or more of the component struc- 
tures of the vulva is not of such rare occurrence, and may be found 
associated with well-formed internal organs of generation. 

Double vulva is an extremely rare condition. The clitoris may 
be absent, bifid, small, or large. 

Atresia of the vulva may be found associated with a communi- 
cation between the rectum, bladder, and genital canal. The foetus 
is rarely viable, but this defect may be found in mature years. 

The infantile type of the vulva may be maintained after puberty. 
The entire vulva, or one or more of the component parts, may 
fail to mature to the full sexual type. Cretins and dwarfs mostly 
retain the infantile type. The vulva may mature at the time of 
puberty, and subsequently undergo atrophic changes involving part 
or all of the vulva. Causes for such atrophy are found in the wast- 
ing diseases, in certain nervous disorders, such as epilepsy, and after 
( 248 ) 



DIAGNOSIS OF DISEASES OF THE VULVA 



249 



removal of the ovaries. A physiological atrophy occurs after the 
menopause. 

Hypertrophy of the vulva rarely involves all structures compos- 
ing the vulva. The clitoris is most commonly affected; it sometimes 
assumes the proportions of the penis, and has been mistaken for it. 

Congenital Fissures of the Vulva, (a) Epispadias is caused by 
failure of closure on the part of the anterior abdominal wall, together 



Fig. 89 
mons veneris 




CLITORIS 



MEATUS 
URINARIUS 



Vulva of a virgin. The labia have been widely separated. (Testut.) 



with a dehiscence of the anterior wall of the alantois. The alantois 
thus communicates with the outer world. 

(6) Hypospadias is formed by a persistence of the urogenital 
sinus. The urethra and vagina open high up in the vestibular 
canal. The perineum is well-developed. The urethra may be 
absent and the bladder communicate directly with the vagina. 



250 SPECIAL DIAGNOSIS 

Here the urogenital sinus has disappeared, and the bladder and 
vagina open directly into the vestibular canal. 

Hermaphroditism. True hermaphroditism has not as yet been 
proven to have an existence. Nagle says that it is not likely that the 
ovaries and testicles can coexist, and without their coexistence true 
hermaphroditism is impossible. 

In pseudohermaphroditism the vulva presents the appearance of 
the male genital organs. The hypertrophied clitoris resembles the 
penis; the coalescence of the labia majora and minora hiding the 
vagina suggests the scrotum. One or both ovaries may descend 
into the coalesced labia and be mistaken for the testicles within 
the scrotum. 

On the other hand, there are males in whom the external genitals 
resemble those of the female. The testicles may either be absent 
or not descended; there may be a small penis, no larger than the 
clitoris, and the scrotum may present a median depression. Where 
the urogenital sinus persists, the male type may be closely simulated. 
In such cases the urethra opens at the base of a very small penis, 
and running from the urethra to the base of the penis is a frsenum. 
Rudimentary labia and hymen lie below the urethra, and above 
this a vagina of variable extent. The uterus and tubes are present, 
but are often quite rudimentary. The general development of the 
pelvis, larynx, and breasts suggests the feminine type. Such indi- 
viduals commonly pass for females, and the true condition may not 
be recognized even after marriage. 

VULVITIS. 

Etiology. In seventy examinations of the secretions found in 
the vestibule, Menge found the streptococcus three times, the 
staphylococcus twice, and the bacterium coli communis once; in 
all cases saprophytic bacteria were found. Menge accounted for the 
infrequency of pathogenic bacteria on the ground of the bactericidal 
action of the vaginal secretion. The tubercle bacillus has been 
demonstrated in the secretions of the vulva by Menge, Chiari, 
Dechamps, and Demure. Diphtheritic vulvitis has been identified 
many times by the finding of the specific organism. 

It has been estimated that 75 per cent, of the cases of vulvitis 
are caused by gonorrhoea. The leptothrix and oidium have been 
demonstrated by Wenkel. 



DIAGNOSIS OF DISEASES OF THE VULVA 



251 



In addition to the above-named essential factors may be men- 
tioned certain exciting causes, such as excessive sexual intercourse, 
masturbation, uncleanly habits, irritating urine, and vaginal secre- 
tions. 

The following varieties are recognized : 

Vulvitis furunculosa, in which multiple small abscesses are found 
upon the labia majora, less frequently upon other portions of the 
vulva. These abscesses are usually found in the sebaceous and 
sweat-glands. Of all the glands of the vulva, the Bartholinean 
glands are most commonly infected, and gonorrhoea is the cause in 



Fig. 90 



Fig. 91 




Enlargement of the vulvovaginal gland by 
cyst or abscess. (Schaffer.) 



Right inguinal hernia simulating vulvo- 
vaginal cyst or abscess. Eversion of anterior 
and posterior vaginal walls. (Schaffer.) 



a great majority of the cases. As a rule, the glands are not exten- 
sively involved. The mouths alone of the glands may be involved, 
giving rise to the so-called *' maculae gonorrhoeica " of Sanger. 
Gebhard affirms that when suppuration occurs in the gland there 
is always a mixed infection of the gonococcus and staphylococcus. 
It is very unusual to observe Bartholinitis in infants. The size 
which these infected glands may attain is from that of a split pea 
to a man's fist. 

The infected Bartholinean gland is located in the labia majora; 
is round or oval, firm or fluctuating, and may or may not be tender. 



252 SPECIAL DIAGNOSIS 

It is to be differentiated from hernia into the labium (Figs. 
90 and 91). The latter is not tender, is elongated, tympanitic on 
percussion, and may be made to disappear by taxis. When reduc- 
tion of the hernia is impossible, and when strangulation and gan- 
grene of the gut have occurred, the usual symptoms of intestinal 
obstruction will suggest the probable nature of the swelling. Evi- 
dence of gonorrhoeal infection elsewhere in the genitourinary tract 
will be suggestive. 

Puerperal vulvitis occurs as the result of an irritating lochial dis- 
charge. A diffuse erythema and ulceration may arise. The ulcers 
are usually superficial, with a gray or brownish colored base and an 
infiltrated margin. A false membrane may cover the ulcerated 
surface, suggesting in appearance a diphtheritic ulcer. The organ- 
ism commonly found in these ulcers is the streptococcus. Very 
rarely the Klebs-Loeffler bacillus is obtained. 

Erysipelatous vulvitis may arise from a primary infection of the 
vulva by the streptococcus of erysipelas. It is frequently observed 
in the newborn. In a case of the author's it spread from the vulva 
to the vagina, uterus, tubes, and peritoneum. 

Tuberculous vulvitis is a rare lesion. Irregular ulcerations are 
found at any point in the external genitals. These ulcers have a 
ragged, undermined margin, with an irregular base covered with 
pus and studded with grayish tubercles. Fistulse may lead to the 
bowel. Extensive cicatrization, causing deformity of the vulva, 
may follow the ulceration. The tubercle bacillus is difficult of 
demonstration in the secretion. The outpour from the involved 
structures may show giant cells and tubercles, more rarely the 
tubercle bacillus. 

Syphilitic vulvitis occurs in the primary, secondary, and tertiary 
stages. In the primary stage the chancre may be found at any 
point on the vulva. The lesion varies in proportion to the asso- 
ciated oedema and cellular infiltration, the greatest swelling occur- 
ring in the labia majora, where the cellular tissue is loosest and 
most abundant. In the secondary stage the vulva is often covered 
with condylomata, which early ulcerate and are covered with a 
slimy secretion of a highly infectious nature. In the tertiary stage 
gummata are rarely found. 

The so-called soft chancre (ulcus molle) has its favorite seat in 
the frsenulum and labia minora. The ulcer formed from the soft 



PLATE XXXII. 




^ 



Vulva of Non-parous Woman, Closed. (Jewett. ) 



PLATE XXXIII. 




>f 



Vulva of Non-parous Woman, Open, Hymen Intact. (Jewett.) 



PLATE XXXIV. 




Vulva of Parous AVoman, Closed. (Jewett.) 



PLATE XXXV. 




4 



Vulva of Parous Woman^ Open. (Jewett.) 



DIAGNOSIS OF DISEASES OF THE VULVA 253 

chancre is round, with a sharp border and a smooth base covered 
with pus. In the neighborhood of the ulcer the vessels are mark- 
edly dilated. 

Actinomycosis of the labia majora has been observed once by 
Lieblenis and again by Bongartz. 

CIRCULATORY DISTURBANCES OF THE VULVA. 

During pregnancy, and in the presence of pelvic tumors and 
inflammatory exudates, the veins of the vulva may be widely dis- 
tended. Thrombosis of the veins and calcareous deposits in the 
coagula (vein stones) are not of infrequent occurrence. (See Plates 
XXXII. to XXXV.) 

Angioma vulvae is a term applied to polypoid protuberances 
formed from dilated veins and blood extravasations. The mass 
is of a bluish color. Rupture of the veins may result seriously. 

HsBmatoma of the vulva may arise from rupture of the veins 
during labor or from direct injury. Such accumulations of blood 
may attain the size of a man's head. While suppuration of the 
blood clot may occur, gradual absorption is the rule. 

(Edema of the vulva may arise from an obstruction to the general 
circulation in diseases of the heart, kidney, liver, etc.; but it is 
more often the result of local interference from pressure of the 
pregnant uterus, pelvic tumors, and exudates. The swelling may 
be bilateral or confined to one side, and may be as large as a child's 
head. 

Gangrene of the vulva has been observed in weakly children, 
in the course of septic febrile diseases, and following pregnancy. 

Hypertrophy of the Vulva. The clitoris and labia majora may 
undergo simple hypertrophy, either as a congenital or as an ac- 
quired lesion. The increase in size may or may not be inflamma- 
tory in origin. Of hypertrophic lesions due to inflammation the 
most common are the condylomata acuminata, which are almost 
invariably of gonorrhoeal origin. Dr. Richard R. Smith reported 
an advanced case in a child nineteen months old (Fig. 92). R. 
L. Dickinson, in discussing *' Hypertrophies of the Labia Minora 
and Their Significance," reported 373 cases and gave as his con- 
viction that all were due to the habit of masturbating. (See Ameri- 
can Gynecology, September, 1902.) 



254 



SPECIAL DIAGNOSIS 



The latter growth is particularly rapid during pregnancy and is 
said to be caused by the irritating vaginal discharge. In the early 
stage of the development these warty outgrowths are pale red or 
gray. Later the papillary projections become confluent and may 
assume the proportions of a man's fist. Occasionally the growth 
is pedunculated. They are found distributed over part or all of 
the vulva, vagina, and the neighboring skin surface of the mons 



Fig. 92 




Condylomata acmninata in a child aged nineteen months. (Case of Dr. R. R. Smith.) 



veneris, groin, buttocks, and perineum. The lesion is essentially 
an overgrowth of the papillae. The greater part of the growth is 
due to an increase in the epithelial covering of the papillae. In 
general appearance such a growth is not unlike a cauliflower car- 
cinoma. The distinction is made by the frequent occurrence of 
the growth during pregnancy; by the history of gonorrhoea, and 
the presence of gonococci in the secretions, together with other 



DIAGNOSIS OF DISEASES OF THE VULVA 



255 



Fig. 93 



evidences of gonorrhoea; by the age of the individual, and, finally 
and conclusively, by the microscopic examination of an excised 
piece in which there is an absence of 
epithelium invading the underlying 
connective tissue. 

Elephantiasis. In the early stage 
of development the growth is not 
unlike simple hypertrophy, but as 
it progresses it tends to become 
more and more pedunculated and 
may extend to the knees, weighing 
several pounds. When the surface 
is smooth it is known as elephan- 
tiasis glabra; when nodular, ele- 
phantiasis tuberculosa, and when 
covered with warty excrescences, 
elephantiasis condylomata. The sur- 
face may be more or less ulcerated 
(Fig. 93). ^ 

The point of origin may be the 
labia majora, labia minora, mons 
veneris, or clitoris. It is unusual 
for the growth to arise simultane- 
ously from two or more of these 
surfaces. 

The greater portion of the growth 
is of connective tissue, with oede- 
matous infiltration of the connective- 
tissue spaces. There is a scant blood 
supply to these growths. 

The essential cause is as yet un- 
known. Elephantiasis sometimes 
arises from the base of old ulcers and 
suppurating buboes. Stenosis or 

occlusion of the lymph channels is undoubtedly an underlying factor, 
but the cause of obstruction to the lymph channel is unknown. 

The patient consults the physician because of the weight of the 
growth and its interference with walking and coition. 

The diagnosis will involve little difficulty. It is distinguished 




Elephantiasis of the vulva, 
and Pettit.) 



(Bonnet 



256 SPECIAL DIAGNOSIS 

from carcinoma by the absence of friability, the slow growth, and, 
finally, by a microscopic section showing an absence of epithelial 
invasion of the connective tissue and the presence of connective- 
tissue hyperplasia. There are no constitutional effects. 

Urethral Caruncle is a localized inflammatory hypertrophy of the 
urethral mucosa located near the external meatus. These elevations 
are usually single, rarely multiple. They attain the size of a hazel- 
nut, are red or bluish-red in color, sensitive to pressure, soft, and 
attached by a broad base or pedicle. The surface is smooth or 
folded, and bleeds but slightly on handling. 

The growth consists in large part of connective tissue infiltrated 
with small round cells, with here and there blood extravasations. 
The surface is commonly covered with several layers of the flat 
epithelium of the vestibule. Tubular glands invade the structure, 
and are lined with epithelium varying in form from flat to columnar. 
Neuberger believes gonorrhoea to be an underlying cause. The 
lesion is frequent in old age. Urination and sexual intercourse are 
painful, because of the great sensitiveness of the caruncles. 

ATROPHY OF THE VULVA (KRAUROSIS VULViE). 

After the menopause there occurs a physiological atrophy of the 
vulva, in which the labia majora lose their plumpness, the labia 
minora diminish in size and may wholly disappear, the clitoris is 
shortened, the mucous membrane becomes dry and pale, and the 
vulvar orifice is narrowed. 

Kraurosis vulvae is a term applied to a specific form of atrophy of 
the vulva, the cause of which is unknown. The extent of the 
atrophy may be greater than the atrophy of old age. The labia 
majora are flat and flaccid, while the mucosa may be so friable as 
to be injured by the examining finger. The labia minora and 
clitoris may wholly disappear. In addition to the dryness of the 
surface there is extreme sensitiveness. Dyspareunia is "a common 
complaint, and when associated with itching and a sense of dryness 
in the vulva the possibility of kraurosis is to be borne in mind 
(Figs. 94 and 95). 

Kraurosis occurs chiefly in women of advanced age; in women who 
have borne children and have become sterile; in the married, and 
in the widow. The lesion sometimes follows removal of the ovaries. 



DIAGNOSIS OF DISEASES OF THE VULVA 



257 



That it is due to syphilis and gonorrhoea is quite improbable. The 
lesion is probably of inflammatory origin. The glandular struc- 



FiG. 94 




Kraurosis vulvae. Clitoris and labia minora completely atrophied; the labia majora 
flattened and wrinkled. (Gerhard.) 



Fig. 95 



i>^'J_i» 



i=X 



"^X 



A^< 







Kraurosis vulvae. Marked hornification of the corium, with round-ceU infiltration; 
papillae are absent. (Gerhard.) 

tures of the affected area disappear; the papillae are poorly devel- 
oped, and the corium is atrophied. 

17 



258 SPECIAL DIAGNOSIS 

NEW-FORMATIONS OF THE VULVA. 

Benign tumors of the vulva are of rare occurrence. 

Fibromata arise from the subcutaneous connective tissue of the 
labia majora and minora, rarely from the clitoris. They are slow 
in their growth, firm, round, and sharply circumscribed. The 
overlying skin is not adherent to the tumor. They are known to 
grow to the size of the patient's head and hang by a pedicle as low 
as the knees. The microscope shows the tumor to be composed of 
connective tissue intermixed with a limited amount of smooth 
muscle fibre. Cystic degeneration and calcareous deposits have 
been described. 

Lipoma arises from the subcutaneous fat of the mons veneris 
and labia minora. They are not so frequently found as are fibro- 
mata. They are usually circumscribed, soft in consistency, some- 
times apparently fluctuating, and are attached either by a broad 
base or pedicle. I am able to find only twenty-two cases of lipoma 
of the vulva in the literature. They are found anywhere from the 
fifth month of infancy to the fifty-first year. 

Enchondroma has not been demonstrated beyond doubt. 

Neuromata have been described as sensitive papillae or warts, 
though the descriptions leave some doubt as to their identity. 

Peckham described a cyst of the clitoris weighing 60 grams, and 
filled with a chocolate-colored fluid. 

Sebaceous cysts are found in the labia, the base of the prepuce, 
and at the base of the hymen. They appear in the form of small, 
yellowish, semitransparent elevations filled with sebaceous material. 
Small, soft-walled cysts lying at the free margin of the hymen may 
be regarded as lymph cysts. 

Dermoid cyst of the vulva is of rare occurrence. 

Vulvar cysts have little clinical significance. An accompanying 
pruritus may disclose their presence. 

CANCER OF THE VULVA. 

The vulva is strangely exempt from infection and malignant 
degeneration. In 1147 cancers of the female genitalia Schwarz 
found 30 to be primary in the vulva. Wenkel tabulated the report 
of 54 cases, in which he found 6 before the age of forty, 16 between 



DIAGI^OSIS OF DISEASES OF THE VULVA 



259 



forty and fifty, 20 between fifty and sixty, and 20 over sixty years 
of age. 

The site of predilection is the outer skin surface of the labia 
majora; less frequent points of invasion are the frsenum, clitoris, 



Fig. 96 




Carcinoma of the vulva. A cauliflower growth two inches in diameter is located in the right 
labium majora. The tumor was friable and bled freely to the touch. 

Bartholinean glands, anterior and posterior commissure, and 
urethral opening. The labia minora are seldom a primary site. 
(See Plate XXXVI.) 

The lesion is characterized by superficial infiltration, by ulcera- 
tion, and by early involvement of the inguinal glands. The growth 



260 SPECIAL DIAGNOSIS 

may be diffuse or circumscribed. The circumscribed growths 
rarely fail to rise above the level of the skin surface. They are 
commonly round or oval, the surface smooth, nodular, or papillary. 
They may grow to the size of a man's fist. At first firm in con- 
sistency, sooner or later they disintegrate and form ulcers more or 
less superficial. The diffuse form may not be evident to the naked 
eye, and is recognized by its rigid, firm feel. Superficial ulceration 
is usually not long in appearing. There is nothing unusual in the 
appearance of the ulcer, the base is uneven, bleeding freely to the 
touch, and covered with a purulent, foul-smelling secretion; the 
margins of the ulcer are irregular, hard, and elevated. In advanced 
cases the ulceration may extend to deep crater-like excavations, with 
markedly infiltrated borders (Fig. 96). 

Schwarz found the inguinal glands infiltrated with cancer cells 
eleven times in twenty-three cases. The rate of growth is often 
slow. The direction to which the growth extends varies. Most 
commonly the extension is to the vagina and from the vagina to 
the rectum, bladder, and pelvic connective tissue. In not a small 
percentage of cases the opposite labium is invaded (contact metas- 
tasis). 

The microscopic characters of vulvar carcinoma differ somewhat 
from those of cancer of the vagina and cervix. There is an unusual 
tendency on the part of the epithelial projections to branch; cancer 
pearls are said to be relatively rare, although in two specimens, 
one removed by Dr. Reuben Peterson, the other by Dr. J. Clarence 
Webster, I found an unusual number of cancer pearls. The exten- 
sion of the cancer cells along the lymphatics gives the appearance 
of veins of marble. Four, cases have been recently reported by 
Peterson {American Journal of Obstetrics, June, 1903), who reviews 
the literature. Cancer of the glands of Bartholin is rare. The 
gland may assume the size of a man's fist, become hard and nodular, 
with a movable, normal appearing overlying skin. The diagnosis 
without the aid of the microscope may be impossible. The lesions 
to be considered in making a diagnosis are the benign new-forma- 
tions (lipoma, fibroma), with ulcerated surface, ulcus rodens, tuber- 
culosis, syphilis, and elephantiasis. In making the diagnosis we 
rely upon the -age of the individual, the general effect upon the 
system, early and superficial ulceration, involvement of the inguinal 
glands, and above all upon the microscopic examination of an 



PLATE XXXVI. 




Cancer of the Vulva. 

Irregular coliamns of epithelixam project from the surface into the coti- 
neetive tissiae. Isolated cancer nests and. pearls are distributed through the 
connective tissue. There is a round-cell infiltration throughout the hyaline 
degeneration of the pearls. 



DIAGNOSIS OF DISEASES OF THE VULVA 261 

excised piece of the tumor. The prognosis is relatively good. 
Schwarz saw ten recoveries in twenty-three cases. 

SARCOMA OF THE VULVA. 

This is a very rare lesion. Hunter Robb has described a myxo- 
sarcoma of the clitoris. Melanotic sarcoma of the vulva is an 
intensely malignant growth. Bailley reported a melanosarcoma in 
a woman, aged seventy-two years. 

Recurrence is almost certain. Miiller removed from the labium 
minora a melanosarcoma as large as a walnut. There was no recur- 
rence until the end of three years. Fisher reports a recovery in a 
woman, aged fifty-six years, from whom a melanosarcoma the size 
of a walnut was removed from the labium major. 

CYSTS OF THE VULVA. 

Cysts of the Bartholinean gland are by far the most frequent of 
the cysts of the vulva. They are not to be regarded as new-forma- 
tions, but rather as retention cysts. Gonorrhoea is the usual exciting 
cause, and hence they are inflammatory in origin. A diagnosis of 
gonorrhoeal infection can be made to a moral certainty from the 
presence of a Bartholinean cyst. Both glands are commonly 
involved, but the lesion is seldom equally advanced on the two 
sides. In the early stage of infection the openings of the glands 
are reddened, and it may be possible to express pus from the gland. 
As the infection extends into the glands they become swollen and 
tender, and if the outlet of the gland is occluded a retention cyst is 
formed. A chronically inflamed cyst may lie quiescent for an 
indefinite period, when through the influence of some mechanical 
insult or secondary infection an acute exacerbation occurs. As the 
glands distend the deep connective tissue is invaded. The infection 
may extend beyond the gland to the loose connective tissue between 
the rectum and vagina, and vagina and urethra. 

The cyst wall is of fibrous tissue lined within by compressed 
epithelium. The wall is usually thin. The contents of the cyst 
are mostly of a thin, serous character, sometimes colloid, purulent, 
or of a dark-red color from admixture with blood. In the contents 
may be found blood corpuscles, blood pigment, cholesterin, pus 



262 SPECIAL DIAGNOSIS 

cells, leukocytes, epithelium, micro-organisms, and detritus. Veit 
reports three cases in virgins with an intact hymen, the probable 
result of a vulvovaginitis. 

Retention cysts of the glands of Bartholin may be unnoticed by 
the patient or discovered accidentally. When there is an inflam- 
matory reaction in and about the gland pain may be intense. 

It is scarcely possible to confuse cysts of the glands of Bartholin 
with any other lesion. Inguinal hernia and cysts of the round 
ligament lie at a higher level and can be traced to the inguinal 
canal. Solid tumors of the labia majora may be excluded by an 
exploratory puncture or incision and by the inflammatory character 
of the growth. 

Cysts of the labia minora are seldom reported. Agnes Bloom,, 
in reporting two cases, gives the following classification: 

1. Cysts arising from the normal structures of the labia minora 
(idiopathic). 

2. Cysts arising from pathological conditions of the labia 
minora. 

3. Cysts arising from Gartner's ducts. While they are commonly 
quite small, they have been known to grow to the size of an orange. 
They are single or multiple, unilocular or multilocular. The con- 
tents vary, being serous, mucous, or purulent. 

ULCERS OF THE VULVA. 

Rodent Ulcer. Virchow was the first to describe this lesion. 
The ulcers present elevated, soft, oedematous margins, are very 
slow to heal, and tend to form fistulous communications with the 
vagina and rectum. W^hen the ulcers invade the urethra, strictures 
and fistulse may follow. The ulcers grow to the size of a silver 
dollar. There is nothing characteristic in the microscopic findings. 
Giant cells suggestive of tuberculosis have been demonstrated. 

The cause is unknown. That they bear no relation to tubercu- 
losis and syphilis has been conclusively demonstrated. Koch is of 
the opinion that these ulcers arise from lymph stasis following sup- 
puration and cicatricial contraction of the inguinal glands. 

The diagnosis presents many difficulties. The lesion is often 
found in combination with elephantiasis, and by many is considered 
a part of this affection. 



DIAGNOSIS OF DISEASES OF THE VULVA 263 

Tuberculous ulcers are distinguished by the presence of the 
tubercle bacillus. Carcinomatous ulcers are not easy to exclude. 
The microscopic examination is essential to a positive diagnosis. 

Syphilitic ulcers are recognized by the history of infection, by the 
general evidence of syphilis which follows, and by the effect of 
treatment. The accompanying elephantiasis is suggestive of ulcus 
rodens. 

PRURITUS VULV-flE. 

Pruritus vulvse is a term applied to an itching of the vulva accom- 
panied by swelling of the parts and nervous irritability. 

The most frequent area involved is the clitoris; next in order of 
frequency are the labia, vestibule, mons veneris, perineum, and 
anus. 

In nearly every instance the lesion is symptomatic, but there is 
a small proportion of cases in which it appears to be idiopathic. 
As a symptomatic lesion the underlying causes are largely attrib- 
utable to mechanical and infectious irritations of the vulva. As 
mechanical irritations may be mentioned masturbation and exces- 
sive sexual intercourse, which may be the result as well as the cause 
of pruritus; also, the wearing of filthy pessaries, uncleanliness of 
the vulva, irritating urine in vesicovaginal fistulse and diabetes, 
and the irritating discharge from malignant growths. Of the infec- 
tious agencies may be mentioned parasites, including the oidium 
albicans, pediculi, and intestinal worms. Any condition bringing 
about passive congestion of the pelvis may cause pruritus vulvse 
in the same manner as hemorrhoids cause pruritus ani. 

It is certain that many of the pelvic lesions may reflexly cause 
itching of the vulva. Pruritus vulvse associated with dryness and 
sensitiveness of the skin suggests the presence of kraurosis of the 
vulva. Disorders of the blood may account for some cases. 
Finally, a small number must be attributed to neurosis, though a 
mechanical cause is always to be sought. 

The diagnosis of pruritus vulvse may be made from the patient^s 
complaint of itching, but it is most essential that the cause of the 
pruritus be determined by a general as well as local physical exam- 
ination. 

As a general proposition we may consider pruritus vulvse a symp- 
tom of some general or local lesion. Every case of pruritus should 



264 SPECIAL DIAGNOSIS 

suggest the possibility of diabetes, and should call for a urinalysis. 
The presence of irritating vaginal discharges, of worms, and of 
parasites are to be sought. The sexual habit of the patient should 
be a subject of inquiry. 

The one dominating symptom is itching over part or all of the 
vulva. So distressing is this itching that the patient becomes irri- 
table and nervous; she shuns society, and may even develop into a 
maniac or suicide. The itching is always worse at the menstrual 
period, during sexual intercourse, in warm weather, and after 
physical exertion. 

Local changes in the skin surface of the vulva are commonly 
present and are largely due to scratching. 

Webster and Sanger independently studied the histological 
changes of the skin removed from the affected area. Webster 
found the genital corpuscles of Krause in the clitoris, and called 
them tactile corpuscles. Nerve endings in the form of end bulbs 
were found in large numbers. A fibrosis of the corpuscles of Krause, 
the end bulbs, and nerves were found by Webster and confirmed 
by Sanger. There was a marked small round-cell infiltration in 
the subepithelial tissues and the superficial epithelium was largely 
removed. 

THE HYMEN. 

A physiological rupture and stretching of the hymen occur from 
sexual intercourse and childbirth. It is possible for the hymen to 
be merely stretched in admitting the penis or in the passage of the 
child. 

The lacerations occurring from the first coition are usually 
radial, and do not extend to the base of the hymen. It is possible 
for the hymen to be partly torn from its base without tearing its 
free margin. As a rule, there is a circular opening. After child- 
birth the hymen is completely severed in many places, leaving 
isolated tags (carunculse myrtiformes). These lacerations often 
extend into the vagina and perineum. 

The question of the existence or absence of a hymen is of medico- 
legal importance. It is self-evident that the hymen is not a reliable 
guide in judging virginity. The hymen may be present and intact 
after sexual intercourse and even after childbirth; while, on the 
other hand, it may be totally wanting or but partially developed in 



DIAGNOSIS OF DISEASES OF THE VULVA 



265 



virgins, 
that no 



It is possible for a lacerated hymen to heal so perfectly 
evidence of a previous laceration is visible. 



Fig. 97 




CRESCENTIC 



FRINGED BILABIAL BIPERFORATE 

Different forms of hymen. (Testut.) 



CRIBRIFORM 



Malformations of the hymen are congenital or acquired. These 
malformations are a double hymen, one beside the other, in cases 
of double vaginae; and hymen imperforatus in connection with 



Fig. 98 



Fig. 99 




CM 



CM 




Hymen after coitus. (Testut.) Hymen after parturition. (Testut.) 

Fig. 98. — C, clitoris; PL, nymphae; U, meatus urinarius; OV, vaginal orifice; H, hymen; 

B, rent in hymen. 

Fig. 99. — XJ, meatus urinarius; P, nymphae; CM, carunculae myrtiformes; Z, portion of 

hymen, detached and floating; D, a tear through the fourchette. 

other malformations of the Mullerian tract. Atresia caused by an 
imperforate hymen may be congenital or acquired. As pointed 



266 SPECIAL DIAGNOSIS 

out by Gellhorn, where the remainder of the genital tract is well 
formed the atresia is undoubtedly acquired. Neugebauer has col- 
lected the report of about 1000 cases of atresia of the hymen from 
the literature, and in about one-half of this number the lesion 
was acquired, and in about one-third of the cases the history gave 
no suggestion of the cause, whether congenital or acquired. Acute 
infectious diseases and gonorrhoea are responsible for the greater 
number of acquired atresias. 

Cysts of the Hymen. Little is known of cysts of the hymen. 
Wenkel made the first report in 1883. Palm describes a cyst of the 
hymen measuring 8 cm. in diameter. The average diameter is 
about 1 cm. Many do not exceed 1 mm. in diameter. They are 
usually congenital, though they may not be observed until late 
years. One or more cysts are located near the free margin of the 
hymen. 

These various sources explain the presence of a variety of epithe- 
lium lining the cyst cavity. As a rule, the epithelium is squamous 
and stratified, but is occasionally cylindrical, and in a few instances 
endothelium is found. 

The origin of the cysts of the hymen is in many cases the epithe- 
lial projections. These projections become constricted off, and 
form the epithelial wall of a space which fills with serum. A few 
cases apparently arise from Gartner's duct, from dilated lymph 
spaces, and from retention of the secretions of sebaceous glands. 

In a valued original communication on the "Anatomy, Pathology, 
and Development of the Hymen" {American Journal of Obstetrics, 
August, 1904), G. Gellhorn presents numerous lesions of the hymen 
not generally recognized. 

Inflammations of the hymen are primary or secondary to vulvitis 
and vaginitis. The inflamed hymen is markedly reddened and 
bleeds easily. The same changes affect the remains of the hymen 
(myrtiform caruncles). Tumors of the hymen are rare. Gellhorn 
finds seventeen cases of hymeneal cysts in the literature, two cases 
of polypi, and one of angioma. Sanger reported a case of primary 
sarcoma of the hymen. As yet no case of primary carcinoma of 
the hymen has been reported. 



CHAPTER XXV. 

THE DIAGNOSIS OF DISEASES OF THE VAGINA. 

Maldevelopments . 
Malformations. 
Vaginitis (Colpitis). 
Para Vaginitis. 
New-formations. 

MALDEVELOPMENTS AND MALFORMATIONS OF THE VAGINA. 

Inasmuch as the vagina is partly developed from the ducts of 
Miiller, developmental failures, analogous to those found in the 
uterus and tubes, are to be found in the vagina. There may be a 
complete absence or a partial development of the vagina; the ducts 
of Miiller may fail to coalesce, giving rise to a double vagina; 
the ducts of Miiller may coalesce, but fail to be absorbed, leaving a 
partial or complete septum, dividing the vagina in the median line. 

Absence of the vagina may result either from a failure of the 
ducts of Muller to develop or from complete atresia. As a rule, 
the entire Miillerian tract fails to develop, hence the absence of the 
vagina, uterus, and tubes. The appearance of the external organs 
of generation niay be misleading in determining the sex. 

Atresia and Stenosis of the Vagina. As a rule, atresia of the 
vagina is incomplete. It is usually the lower segment that is closed. 
In extreme cases only a fibrous or fibromuscular band is found 
between the bladder and rectum. Back of the obstruction the 
menstrual blood collects in the vagina (hsematocolpos) ; in the 
uterus (hsematometra) ; in the tubes (hsematosalpinx), and, finally, 
in the pelvis (hsematocele) . 

The obstructing tissue may be stretched and crowded down, 

appearing at the vulvar outlet as a dark bluish-red membrane. 

The retained blood does not usually coagulate, but becomes dark 

in color. 

( 267 ) 



268 



SPECIAL DIAGNOSIS 



Etiology. Atresia of the vagina may be congenital or acquired. 
It may be difficult to determine whether the malformation developed 
in intrauterine or in extrauterine life. In very young infants a 
vaginitis may form adhesions of the vaginal surfaces without giv- 
ing rise to symptoms. Whether a fetal vaginitis can account for 
congenital atresia of the vagina has not been demonstrated. 

The usual cause of stenosis and atresia of the vagina occurring 
during the period of sexual maturity is trauma incident to labor. 



Fig. 100 



Fimbriated extremity 
of tube. 



Broad ligament, 
upper part. j. 




\ 
Artery 

vein. 



Vagina, anterior wall. 



The uterus and its appendages. Posterior view. The parts have been somewhat dis- 
placed from their proper position in the preparation of the specimen; thus the right ovary- 
has been raised above the Fallopian tube and the fimbriated extremities of the tubes have 
been turned upward and outward. (From a preparation in the Museum of the Royal College 
of Surgeons of England.) 



In the postclimacteric stage an adhesive vaginitis may narrow 
or obliterate the vagina. Gonorrhoea is the usual underlying 
cause of senile vaginitis. In congenital atresia the obstruction is 
most often at the junction of the middle and upper third of the 
vagina, which is the lower limit of the Miillerian ducts. In the 
acquired form the obstruction is usually similarly situated. 

The obstruction may be merely a half-moon or annular ring, a 
partial or complete septum with perforations, or a membrane vary- 
ing in thickness even to filling the vagina completely. Two, three, 
and even four atresic points have been described. 



DIAGNOSIS OF DISEASES OF THE VAGINA 



269 



The diagnosis of stenosis and atresia of the vagina should present 
few difficuhies. When a girl at the time of puberty fails to men- 



FiG. 101 



Fig. 102 





Fig. 101. — Atresia at the vulva first causes distention of the vagina, producing hemato- 
colpos. (Sutton and Giles.) 

Fig. 102. — Atresia at the vulva. Hsematotrachelos has followed hEematocolpos. (Sutton 
and Giles.) 



Fig. 103 



Fig. 104 





Fig. 103. — Atresia of the vulva has caused hsematocolpos, then hsematotrachelos, and then 
haematometra. (Sutton and Giles.) 

Fig. 104. — Atresia at the vulva. In addition to the conditions in Fig. 103, there is added 
hsematosalpinx. (Sutton and Giles,) 



270 SPECIAL DIAGNOSIS 

struate, but suffers from pain in the pelvis, which increases in 
severity at the time of each monthly period, atresia of the vagina 

Fig. 105 Fig ' 106 Fig. 107 






Fig. 105.— Atresia in the vagina midway between the vulva and the os externum, causing 
haematocolpos in the upper half of the vagina. (Sutton and Giles.) 

Fig. 106.— Same as in Fig. 105, except that distention of the whole uterus has followed 
the partial haematocolpos. (Sutton and Giles.) 

Fig. 107.— Atresia of the os externum, producing a hsematotrachelos. Corpus uteri not 
yet distended. (Sutton and Giles.) 

Fig. 108 Fig. 109 





Fig. 108.— Atresia of the os internum, producing hsematometra. Fallopian tubes may 
become distended later. (Sutton and Giles.) 

Fig. 109.— Atresia of the vulva on one side of a double uterus and vagina, causing a 
haematocolpos on the affected side. (Sutton and Giles.) 



DIAGNOSIS OF DISEASES OF THE VAGINA 



271 



or cervix is suspected. If, in addition, a pelvic tumor develops and 
distinctly fluctuates, the diagnosis is highly probable, but must 
be confirmed by a vaginal examination. Vicarious menstruation 
rarely occurs. In an attempt to make a digital examination of 
the vagina the finger will meet the obstruction. The extent of the 
closure is best determined by the finger in the rectum. If the 
obstruction lies high in the vagina and does not bulge downward 
it is not likely that there is any considerable secretion pent up 
above the point of obstruction (Fig. 110). 



Fig. 110 




Vaginal septum. The index finger inserted into the urethra and the thumb in the rectum 
are approximated, and by so doing the atresic vagina is demonstrated. 



Hsematometra is not easy to demonstrate, because of the difficulty 
in palpating the elevated uterus through the rectum. The uterus 
usually lies near the median line, and is rounded, tense, possibly 
fluctuating, and somewhat increased in size. 



272 SPECIAL DIAGNOSIS 

Double vagina is the result of failure on the part of the Mullerian 
ducts to perfectly fuse. From this cause a septum divides the 
vagina in part or throughout. The vaginal canals usually lie side 
by side, the septum running anteroposteriorly. The canals may be 
unequal in size. The septum rarely runs transversely, so dividing 
the vagina that one lies in front of the other — this can only be 
accounted for on the supposition that the Mullerian ducts had 
rotated prior to their fusion. All degrees of development may be 
observed in the septum, from a slight ridge to a complete partition 
composed of fibrous tissue, mingled with some muscle fibres and 
covered on either side with mucous membrane. The cervix and 
uterine body are usually divided. 

If both canals are pervious no symptoms need arise until labor, 
when there may be an obstruction to the passage of the child. 

VAGINITIS (COLPITIS). 

Vaginitis rarely exists singly. As a rule, it is associated with 
vulvitis and endometritis, and not infrequently with a similar 
involvement of the entire genital tract. 

Etiology. With few exceptions vaginitis is due to bacterial 
invasion. Mechanical and thermic irritants are accountable for a 
small number of cases. 

Of the micro-organisms causing vaginitis the gonococcus is by 
far the most frequent. A purulent discharge from the cervix con- 
taining the gonococcus may fail to infect the vagina because of 
the protecting epithelium, which, when intact, resists all bacterial 
invasion. 

If, however, the epithelium of the vagina is lost or its vitality is 
lowered infection will follow. We, therefore, find primary gonor- 
rhoeal vaginitis less frequently in the young than in advanced years, 
when the epithelium has lost its full power of resistance and is more 
or less desquamated. Repeated attacks of vaginitis may result 
from contamination by the secretions of the uterus, tubes, and 
urethra. It is said that chronic gonorrhoeal vaginitis does not exist. 

Injudicious exercise and sexual excesses may be the explanation 
of exacerbations. 

Puerperal vaginitis is nearly always caused by the staphylococcus 
and streptococcus. The Klebs-Loeffler bacillus is rarely the cause 



DIAGNOSIS OF DISEASES OF THE VAGINA 273 

of vaginitis. The streptococcus of erysipelas is occasionally found, 
particularly in infants. The presence of the oidium albicans and 
leptothrix has been demonstrated. Entozoa can invade the vagina 
from the rectum. Ascarides and similar parasites of the intestines 
may invade the vagina and set up a vaginitis. 

Infections from the bowel, as from dysentery and typhoid fever, 
may invade the vagina. Infection may also travel from the bladder 
to the bowel. An irritating and infectious discharge from the 
uterus or from a pelvic abscess opening into the vagina will infect 
the vagina. It is highly probable that maceration of the epithelium 
by fluids used in douching favors infection from such discharges. 

The secretions from malignant growths of the uterus are particu- 
larly irritating to the vaginal mucosa. 

Trauma from ill-fitting and foul pessaries, from tampons saturated 
with irritating secretions, and from masturbation predisposes to 
infection. Schultze has correctly claimed that decomposition of 
stagnated menstrual blood behind the hymen in chlorotic girls is 
not infrequently a cause of vaginitis. 

Tumors lying within the vagina may act as mechanical irritants 
to the vaginal mucosa. 

Anatomical Diagnosis. The following morphological forms are 
recognized : 

1. Catarrhal vaginitis is recognized by a reddening, swelling, and 
increased secretion of the vaginal mucous membrane. These 
changes are proportional to the degree of acuteness and intensity 
of the infection. The surface is rarely uniformly red, but rather 
mottled red and gray. In the chronic stage slight reddish eleva- 
tions stud the surface. These elevations are particularly prominent 
in old age when contrasted with the smooth, pale-gray background. 

The microscope shows a diffuse round-cell infiltration and capil- 
lary congestion of the subepithelial connective tissue. There may 
be more or less desquamation of the surface epithelium. The deep 
layers of connective tissue are rarely involved. In the senile variety 
punctate hemorrhages are particularly liable to occur in the connec- 
tive tissue. Gebhard speaks of a variety called croupous vaginitis, 
in which there is formed on the surface a false membrane com- 
posed of fibrin, leukocytes, desquamated and degenerated epithe- 
lium. He observes that a similar lesion is often found in the bowel, 
and reasons that there is a specific cause underlying both conditions, 

18 



274 ^ SPECIAL DIAGNOSIS 

2. Ulcerative Vaginitis. It is possible for ulcers to develop in 
the advanced stage of catarrhal vaginitis; this, however, is excep- 
tional. The loss of epithelium is usually superficial, and in healing 
does not lead to cicatrization. 

a. Puerperal ulcers of the vagina arise from infection of abrasions 
and lacerations acquired in labor. A diphtheritic membrane of 
a gray or yellowish-gray color forms over the ulcerated surface. 
The lesion may extend deeply into the vaginal wall and into the 
paravaginal connective tissue. Pelvic abscesses and suppurative 
peritonitis may follow from extension of the infection. A diffuse 
tumefaction and reddening of the vaginal mucous membrane may 
extend from the ulcers, giving the appearance of erysipelas. 

Stenosis and atresia of the vagina may follow healing by cicatriza- 
tion, particularly when the paravaginal tissues are involved. 

h. True diphtheritic ulcers of the vagina, in which the Klebs- 
Loeffler bacillus appears, is a rare finding, and almost always 
develops during the puerperium. 

c. Tuberculous ulcers of the vagina are of rare occurrence. Such 
ulcers are shallow, with irregular undermined margins. The base 
and margins are studded with miliary tubercles, in which the 
tubercle bacillus may be demonstrated. 

d. Syphilitic ulcers in the primary stage with elevated indurated 
margins are more common than those of the secondary or tertiary 
stage. 

Ulcers of the vagina complicating the infectious diseases, as, for 
instance, typhoid fever and smallpox, are occasionally seen. 

e. Decubitus ulcers arising from pressure by foreign bodies in the 
vagina show great variation .in extent and form. The common 
cause of decubitus ulcers is the wearing of ill-fitting pessaries, 
which, through pressure, cause a superficial slough of the mucosa. 
The necrosis may extend deep into the tissues and result in the 
development of a vesicovaginal fistula. Such ulcers may attain 
the size of a saucer. 

3. Tuberculous Vaginitis. But one case of primary tuberculosis 
of the vagina has been reported (Friedlander). The usual tubercu- 
lous lesions are found — that is to say, local or general dissemination 
of tubercles, larger tuberculous nodules, and caseous masses with 
ulcers. The microscope reveals the usual structure of tubercles: 
giant cells, sniall round cells, endothelioid cells, and tubercle bacilli. 



DIAGNOSIS OF DISEASES OF THE VAGINA 275 

« 
By far the greater number are secondary to tuberculosis of the 

uterus, tubes, vulva, cervix, rectum, and bladder. The infection 

may very rarely be conveyed by the blood. Primary infection 

may be acquired by direct infection from the husband and from 

the examining finger and instruments. 

4. Emphysema vaginae (colpitis emphysematosis). As the result 
of some sort of an infection numerous small cysts filled with gas are 
found in the subepithelial connective tissue. The lesion usually 
appears in pregnancy and the puerperium. As a rule, the cysts 
disappear within three months after labor. 

Wenkel first described them as retention cysts formed from 
vaginal glands. Zweifel first demonstrated them to be the result of 
fermentation. Eisenlohr proved the presence of gasogenic bacteria 
in the connective-tissue spaces of the submucosa and of the lymph 
spaces. There can be no doubt as to the microbic origin of the 
lesion. Through a speculum the vesicles appear dark bluish-red 
in color. Pressure causes them to temporarily disappear. If the 
vagina is partly filled with clear fluid and the vesicles punctured 
with a needle, gas will escape in bubbles. 

5. Condylomatous Vaginitis. Groups of warty excrescences are 
found in the vagina as further extension of a similar growth of the 
vulva. The whole vaginal surface may be covered with the warty 
growth. 

Clinical Diagnosis. In all forms of vaginitis there is an exces- 
sive secretion, varying in quantity and character. The secretion 
is derived in part from the uterus and cervix. It is serous, mucous, 
or purulent. This so-called leucorrhoea (''whites") is usually the 
first symptom. Following this is itching and burning, which is 
aggravated by exercise. When caused by gonorrhoea these symp- 
toms may appear within twenty-four hours from the time of the 
infection. In addition to the above symptoms there is usually 
burning and smarting on urinating, caused by a urethritis. 

When pus can be expressed from the urethra the diagnosis of 
gonorrhoea is made with reasonable certainty. If in addition the 
Bartholinean glands are infected, there can be little doubt as to 
the gonorrhoeal origin of the lesion. 

Vesical and rectal tenesmus are present in the acute stage. In 
the mild forms and in the chronic stage the patient may not com- 
plain. 



276 SPECIAL DIAGNOSIS 

The diagnosis has to do, first, with the recognition of the vaginitis; 
next, with the possible extension of the lesion to neighboring struc- 
tures; and, finally, with the underlying cause of the infection. 

Direct inspection should determine the presence of vaginitis. 
The Sims speculum should be used with the patient in the Sims 
position. There is more or less sensitiveness to the touch of the 
examining finger, and a roughness of the surface may be detected. 

The recognition of extension to the upper genital tract involves 
the diagnosis of endometritis and salpingitis. To determine whether 
the secretion is from the vagina or from the uterus the Schultze 
method is employed. The vagina is cleansed with a douche of 
sterile water, a plug of sterile cotton is placed against the cervix, 
and after remaining there several hours it is removed. If the secre- 
tion is collected on the top of the plug, the discharge comes from 
the uterus; if it collects around the plug, the discharge is from the 
vagina. 

Recognition of the cause of the infection is not always possible. 
Gonorrhoea is so frequently the cause that it must first be excluded 
before considering other possible causes. In the acute stage the 
gonococcus can usually be found in the secretion, but not often in 
the chronic stage. When beginning a few days after marriage and 
associated with burning on urinating, it is highly probable that 
gonorrhoea is the underlying cause. 

PARAVAGINITIS. 

By paravaginitis is understood an inflammation involving the 
connective tissue immediately surrounding the vagina. As a rule, 
it is a staphylococcus infection leading to the formation of localized 
abscesses. Other possible causes are wound infections following 
operations and attempts to induce abortion; ill-fitting pessaries, 
which have ulcerated through the vaginal wall; infectious diseases, 
such as dysentery and typhoid fever, where the infection is con- 
veyed through the bowel or bladder into the paravaginal connective 
tissue, and in all inflammatory diseases of the rectum and bladder 
extending to the vagina. 

Veit describes a peculiar form which he designates as paravaginitis 
phlegmonosa dessecans. But few cases have been recorded. One 
was ascribed to gonorrhoea; others may have been due to criminal 



DIAGNOSIS OF disi:asi:s of the vagina 



277 



abortion, and in two instances no cause was assigned. Undoubtedly 
the lesion may arise as a complication of contagious and infectious 
diseases. Cicatricial contraction of the vagina is the final result. 

NEW-FORMATIONS OF THE VAGINA. 



Cysts of the Vagina. Cysts of the vagina are not of great 
rarity. Neugebauer found thirty-six cases in 600 observations 
(Fig. 111). 



Fig. Ill 




Cyst of the anterior wall of the vagina. A thin-walled, translucent cyst protrudes from 
the vulva. Such a growth may be mistaken for an inverted uterus or a complete prolapsus 
uteri. The cyst fluctuates, there are no tubal or cervical openings, and the uterus is found 
in its normal position by a rectoabdominal examination. 

Histogenesis. The fact that the epithelial lining of the cysts 
varies in form suggests various origins. Veit believes them to 



278 SPECIAL DIAGNOSIS 

develop from remains of the Wolffian ducts. The ducts of Gartner 
do not ordinarily extend below the vault of the vagina, but instances 
are known in which they extended as far as the urethral opening 
along the lateral and anterior walls of the vagina. In these ducts 
muscle fibres and cylindrical epithelium are observed, and so it is 
that cysts located in the sides or in the anterior wall of the vagina 
and containing muscle fibres and epithelium are assumed to arise 
from the ducts of Gartner. As further evidence of this origin, may 
be mentioned their occasional elongated form with their long axis 
in a line corresponding to the long axis of the vagina. Still more 
significant is the rosary-like arrangement of two or more cysts along 
the line of Gartner's duct. 

Preuschen suggests that the origin of vaginal cysts may be the 
glands of the vagina. Cysts lying in the posterior wall of the 
vagina are thus explained. They are regarded as retention cysts. 
Davidson holds that the glands of the vagina are purely misdevel- 
opments. Those in the upper segment of the vagina are misplaced 
from the cervix and maintain the character of cervical glands, while 
those in the lower segment of the vagina are from the vulva. Reten- 
tion cysts arising from these glands are usually multiple, of small 
size, and lined with a single layer of columnar epithelium. Cysts 
may arise from partial adhesion of the folds of vaginal mucous 
membrane enclosing spaces lined with flat epithelium. 

Freund believes that cysts of the vagina arise from rudimentary 
ducts of Miiller. Furthermore, it is apparent that the lymph spaces 
may distend into cysts lined by endothelium. 

Cysts of the vagina are rarely of large size, ranging from that of 
a pinhead to a hazelnut. In exceptional cases they are found the 
size of a child's head. They are slow in growth. The sites of 
election are the anterior and lateral walls, rarely the posterior wall 
of the vagina. They lie immediately underneath the epithelium, 
and bulge into the vagina. The consistency is elastic; the contents 
clear, watery, or mucoid. Occasionally the contents are milky 
from the presence of degenerated epithelium; sometimes chocolate 
color from admixture with blood. Cheron reports the presence 
of a stone in a cyst. Cholesterin crystals are occasionally found. 
As a rule, the cysts are simple, but they may be multilocular. The 
cyst wall is composed of fibrous tissues, occasionally mingled with 
some muscle fibres. The inner surface is lined with a single layer 



DIAGNOSIS OF DISEASES OF THE VAGINA 279 

of cylindrical epithelium, sometimes with several layers of cylin- 
drical or flat epithelium; rarely are endothelial cells found. 

They are seldom of clinical interest, but are known to interfere 
with sexual intercourse and with childbirth, and have been mis- 
taken for prolapsus uteri and inversion of the uterus. 

FIBROMYOMA OF THE VAGINA. 

Richard R. Smith collected 101 cases from the literature. They 
commonly occur between the ages of twenty and forty years, and 
have been observed as early as one and one-half years and as late as 
seventy-eight years. The largest one recorded weighed ten pounds. 
They are usually round and attached by a broad base or pedicle. 
The surface is smooth or nodular, and is covered with vaginal 
mucous membrane. They are seldom of soft consistency. Their 
origin is in the submucous connective tissue. They are rarely 
multiple, and are most often located in the anterior wall of the 
vagina. The usual forms of degeneration common to fibroids are 
possible. 

The diagnosis is not difficult. A soft fibroid might be mistaken 
for a cyst, a cystocele, or a rectocele. The bluish, semitransparent 
color of the cyst is of special significance. 

CARCINOMA OF THE VAGINA. 

Etiology. Less than 1 per cent, of all cancers in women are of 
vaginal origin (Williams, Bristol). Kustner collected twenty-two 
cases of primary cancer of the vagina, and estimates that about 0.02 
per cent, of cancers of the genital tract arise primarily in the vagina. 

As a rule, primary carcinoma of the vagina arises between the 
ages of fifty and sixty; two cases are reported at twenty years 
of age. Childbearing does not influence the development of the 
growth, and heredity plays a minor role. A number of cases have 
been recorded where ill-fitting pessaries have caused ulceration and 
eventually malignant degeneration. Prolapse of the vaginal walls 
subjects the vagina to mechanical insults, and upon the injured 
surface may be engrafted a carcinoma (Fig. 112). 

Anatomical Diagnosis. In 123 cases 71 were found on the 
posterior vaginal wall, 13 on the lateral walls, and 16 were annular. 



280 



SPECIAL DIAGNOSIS 



The growth may be papillary, nodular, or infiltrating. To the 
unassisted eye cancer of the vagina usually presents a thickened, 
ulcerated area. The margins are irregular, hard, and elevated. 



Fig. 112 




Primary carcinoma of the vagina. On the posterior wall of the vagina is an irregular 
infiltrated area, friable and bleeding. 

The base of the ulcer is uneven, bleeds freely on handling, and 
is covered with a foul-smelling secretion. Surrounding the vagina 
the tissues show an inflammatory reaction, and secondary nodules 
may be seen distributed over the surface. Rarely does the growth 



DIAGNOSIS OF DISEASES OF THE VAGINA 281 

attain the size of a man's fist. Extension into the paravaginal 
tissue is rapid. Reaching the lymph spaces of the connective tissue, 
the cancer cells are rapidly carried to the retroperitoneal glands. 
The inguinal glands are enlarged when the lower segment of the 
vagina is invaded. As a rule, the uterus is not invaded so early 
as the vulva, and metastasis to distant organs is late. The micro- 
scope shows nothing unusual. It is a flat-cell growth, the cells are 
arranged in nests, and contain many pearls. 

Clinical Diagnosis. The lesion may go unrecognized until far 
advanced. As with cancer of the uterus, all symptoms may be 
wanting until there is ulceration and sloughing of the growth. 
Hemorrhage, pain, and a foul-smelling discharge are the cardinal 
symptoms, but in no way do they differ from the same group found 
in cancer of the vulva or uterus. Pain is rarely present until the 
growth has extended into the paravaginal tissue. All observers 
have noted the absence of pain in the early stage. 

Stenosis of the vagina may hide a growth lying above the point 
of constriction, and render the early diagnosis very difficult. 

Secondary cancer of the vagina is of frequent occurrence. Cancer 
of the cervix is especially liable to extend to the vagina. Normal 
tissue may intervene between the primary growth in the cervix 
and the secondary growths in the vagina. Cancer of the bladder 
and rectum more rarely invade the vagina. Metastatic growths from 
the ovary are seldom found in the vagina. 

Wahn, Fisher, and Kalkenbach report implantation of cancer 
cells upon eroded surfaces in the vagina through the medium of 
a leucorrhoeal discharge. The secondary growths take the same 
histological forms as the primary growth. 

The average duration of primary cancer of the vagina is said to 
be sixteen months, but may last several years. 

Differential Diagnosis. Decubitus ulcers caused by ill-fitting 
pessaries may be mistaken for carcinoma, and have been known 
to be its starting point. The hard, elevated margins, friable, and 
bleeding when handled, are distinctive of malignancy. Where 
doubt exists a microscopic examination of an excised piece, or 
a scraping from the suspected portion, will determine the diag- 
nosis. 

Syphilitic and tuberculous ulcers of the vagina are recognized by 
the clinical history, by evidences of lesions elsewhere in the body, 



282 SPECIAL DIAGNOSIS 

and by microscopic examination of excised pieces. Friability and 
bleeding of the suspected tissue are suggestive of carcinoma. 

SARCOMA OF THE VAGINA. 

Sarcoma of the vagina is found in all ages, from the first to the 
eighty-second year. Six so-called congenital cases are reported. 
Of forty cases reported by Williams, thirty-six occurred before 
fifteen years of age. 

The growth is usually polypoid, of a yellowish-gray or chocolate 
color. Rarely is there a diffuse infiltration of the vaginal walls. 
The surrounding structures are early invaded. Distant metastasis 
is late, and often does not occur. There is a tendency to early 
necrosis of the tumor mass, together with infection of the necrotic 
mass by pyogenic micro-organisms leading to cystitis, pyonephritis, 
and peritonitis. 

Late in life sarcoma is usually smooth rather than rough and 
polypoid as in early life. 

Histologically, the growth is demonstrated to be a fibrosarcoma, 
myxosarcoma, round-cell or spindle-cell sarcoma, or, finally, a 
melanosarcoma. 

The diagnosis of sarcoma apart from carcinoma cannot be made 
without the aid of the microscope. 

SYNCYTIOMA VAGIN^ffi. 

Syncytioma malignum (or, as better named, chorioepithelioma 
malignum) occurs with relative frequency as a secondary growth in 
the vagina. 

Schmidt lately reported two cases of primary growths in the 
vagina. In both cases the uterus remained perfectly normal. 

Kiible removed a primary syncytial growth from the vagina, and 
in twenty days it had recurred. 

All new-growths of the vagina developing weeks and months 
after labor should be incised and examined with special regard for 
malignant proliferation of the syncytium. 

To the unaided eye the tumor is usually round and elevated. It 
is of a bluish color. Ulceration is rare. On cross-section the tumor 
is exceedingly bloody, and may resemble a blood clot. 



PLATE XXXVII. 



A. 




■''^}. 



















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;i-^A^V;:-ti:-c?' 






,^^^ 






'-■•i'^-— •''' ' '_:!•■ 



TV'.'" •:••* — . -' 



- -.^V<. vMh-^ g: 






Chorioepithelioma Malignum of the Vagina. 

A nodule appeared in the wall of the vagina several months after an appar- 
ently normal labor. The case was reported by Schmidt, of Vienna. The accompany- 
ing illustration was drawn from a section of the nodule loaned from the collection 
of Dr. Frank D. Pierce. It represents a covering of normal stratified squamous 
epithelium. Beneath this is a variable thickness of connective tissue overlying a 
large clot of blood in which are seen two villous stems covered by proliferating 
svncvtium. Svncvtial cells are seen to invade the blood clot. 



DIAGNOSIS OF DISEASES OF THE VAGINA 283 

ENDOTHELIOMA OF THE VAGINA. 

Endothelioma of the vagina is an exceptional growth. The first 
case was reported by Klein. By the naked eye the growth cannot 
be distinguished from a carcinoma. Microscopically the tumor is 
found to be composed of cells resembling flat epithelium arranged 
in a thick meshwork of connective tissue. The cells arise from the 
endothelium of the blood or lymph spaces. In distribution they 
resemble veins of marble. 



CHAPTER XXVI. 

ENDOMETRITIS. 

A. Clinical Classification. 

I. Acute Endometritis. 
11. Chronic Endometritis. 

1. Hemorrhagic. 

2. Catarrhal. 

3. Dysmenorrhoeic. 

4. Tuberculous. 

5. Gonorrhoeal. 

6. Decidual. 

7. Puerperal. 

8. Postabortive. 

9. Exfoliative. 
10. Senile. 

B. Anatomical Classification. 

I. Macroscopic Forms. 

1. Hypertrophic. 

2. Fungous. 

3. Villous. 

4. Polypoid. 

5. Ulcerative. 

6. Pseudodiphtheritic 
II. Microscopic Forms. 

1. Glandular. 

a. Hypertrophic. 
h. Hyperplastic. 

2. Interstitial. 

3. Mixed. 

Matthews Duncan once said in a lecture: " Who can tell 
what anyone means by endometritis? Often its use is the parent 
or child of ignorance and confusion." There is yet to be pro- 
posed an exact and practical classification of endometritis. In 

( 284 ) 



ENDOMETRITIS 285 

the light of our present knowledge we are unable to harmonize 
our clinical, macroscopic, and microscopic forms of endometritis. 
In making a diagnosis from prominent symptoms and evident 
etiological factors we are unable to foretell the naked-eye and 
microscopic findings. One and all of the pathological forms of 
endometritis may exist without clinical signs. On the other hand, 
any of the pathological lesions of the endometrium may give the 
same clinical manifestations as endometritis. Furthermore, these 
symptoms may be present in the absence of an evident pathological 
change in the endometrium. 

It is evident that a clinical classification cannot be universally 
applied. While appropriate to the majority of cases, there will be 
a minority which can only be recognized by direct examination 
of the endometrium with the naked eye or with the microscope. 
Indeed, it not infrequently occurs that the absolute diagnosis is 
reserved for a microscopic examination of scrapings removed by the 
curette. In view of what has been said there will be given both a 
clinical and an anatomical classification. 

A. CLINICAL CLASSIFICATION OF ENDOMETRITIS. 

Endometritis may be acute or chronic. The distinction between 
these forms is usually not difficult to make. 

I. Acute Endometritis. 

In acute infections of the endometrium the constitutional dis- 
turbances may be mild or severe. Fever may exist, but is not always 
proportionate to the extent and intensity of the inflammation. The 
pulse rate corresponds to the degree of general intoxication, and is 
to be regarded as a more reliable indication of systemic infection 
than is the temperature. The menses are lessened or suppressed. 
The uterine discharge is at first serous, later seropurulent. There 
is backache, nausea, a sense of weight in the pelvis, rectal and 
vesical tenesmus, and pain in the hypogastrium. Bimanual exam- 
ination reveals a uterus tender to pressure, not perceptibly increased 
in size, and perfectly movable. The external os may be slightly 
patulous and softer than is normal. Inspection through the specu- 
lum shows a congestion of the cervix which is particularly evident 
at the external os. From the cervical canal flows a seropurulent 



286 SPECIAL DIAGNOSIS 

or mucopurulent secretion; rarely is it clear, serous or mucous. 
A sound introduced into the uterus would cause some pain and 
bleeding, and should not be used. 

II. Chronic Endometritis. 

For practical clinical purposes we will adopt a classification of 
endometritis based upon the prominent clinical symptoms — hemor- 
rhage, leucorrhoea, and pain, and will speak of hemorrhagic, catar- 
rhal, and dysmenorrhoeic endometritis. 

Clinical Forms of Chronic Endometritis. 1. Hemorrhagic 
endometritis is characterized by an unusual loss of blood during 
and sometimes between the menstrual periods. Inasmuch as the 
normal limits of menstruation vary widely, it is difficult to fix the 
exact limitations of the normal and the abnormal flow of blood. 

The normal limits in time may be fixed at from two to eight days ; 
a flow continuing longer than eight days may be regarded as patho- 
logical. The average normal quantity of menstrual blood is six to 
eight ounces. Intermenstrual bleeding is always pathological and 
demands careful inquiry into the cause. It is unusual for endo- 
metritis to cause intermenstrual bleeding. Physical exertion may 
excite hemorrhage, but the loss of blood is never considerable. In 
hemorrhagic endometritis, leucorrhoea and pain may be present, 
but these are symptoms of less prominence than is the hemorrhage. 

2. Catarrhal endometritis is characterized by an excessive serous 
or seropurulent discharge from the uterus. The amount of secre- 
tion is not proportionate to the extent and degree of inflammatory 
change found in the endometrium. If mucus is found in the secre- 
tions, the cervix is involved, there being no mucous secretion from 
the body of the uterus. 

To differentiate a uterine discharge from the secretions of the 
vulva and vagina the Schultze method should be adopted. (See 
page 54.) 

Not infrequently women complain of a leucorrhoeal discharge 
during pregnancy and immediately preceding and following the 
menstrual flow. Such are within normal limits, and are to be 
regarded as hypersecretions of the congested uterus, vagina, and 
vulva. 

The most excessive discharge is found in gonorrhoeal endometritis. 
Nothing can be ascertained respecting the essential cause of the 



ENDOMETRITIS 287 

infection from the macroscopic appearance of the discharge. Cover- 
sHp preparations may contain the gonococcus. 

3. Dysmenorrhceic endometritis is characterized by painful men- 
struation. Pain is httle to be rehed upon in the diagnosis of endo- 
metritis. The diagnosis is arrived at by excluding all other possible 
causes of pain. The pain of endometritis is described as being of 
a cramping, bearing-down character, and associated with a feeling 
of weight in the pelvis. However, there is nothing characteristic 
in the pain. It is more often caused by such complicating lesions 
as salpingitis, ovaritis, and perimetritis. 

While the above-named symptoms — hemorrhage, leucorrhoea, 
and pain — are commonly present in endometritis, and while one of 
the three symptoms usually dominates and justifies the terms as 
given above, it is not uncommon for endometritis to give rise to no 
symptoms. Furthermore, carcinoma, sarcoma, submucous polyps, 
and retained placental tissue may closely simulate endometritis in 
their clinical manifestations. In addition to the above clinical 
forms of endometritis may be mentioned several varieties which are 
not only hemorrhagic, catarrhal, or dysmenorrhceic, but are deserv- 
ing of special designation because of some point of interest relating 
to their etiology, time, and manner of occurrence. The following 
forms are ordinarily recognized : 

4. Tuberculous endometritis often follows a primary infection of 
the tubes. Where tuberculous salpingitis is recognized, and there 
develops a catarrhal discharge from the uterus, the extension of the 
tuberculous process to the endometrium is suspected. Frequently 
there is amenorrhoea. Cover-slip preparations should be taken 
from the secretions and an exploratory curettage may be made, 
with the view of finding giant cells, tubercles, and the tubercle 
bacillus in the scrapings. 

5. Gonorrhceal endometritis can be recognized with absolute cer- 
tainty only by finding the gonococcus in the catarrhal secretion. It 
is not always possible to demonstrate the presence of the gonococcus 
in the secretions ; this is particularly true of the long-standing cases. 
When a leucorrhoeal discharge appears shortly after marriage, and 
when in addition to leucorrhoea there is burning on urinating and 
infection of the urethra and glands of Bartholin, little doubt can 
be entertained as to the nature of the infection. No other form 
of endometritis causes such profuse discharge. 



288 



SPECIAL DIAGNOSIS 



6. Decidual endometritis is a term applied to the inflammation 
of the endometrium of pregnancy. The lesion can only be sus- 
pected during pregnancy. A positive diagnosis is made by a micro- 
scopic examination of the decidua after the expulsion of the foetus. 
Gonorrhoea is the usual cause. The symptoms are hemorrhage, 
which varies in amount and may continue throughout pregnancy; 
leucorrhoea of a purulent character, less often serous, sometimes 
known as hydrorrhoea gravidarum; and pain of a cramping or 
bearing-down character. The leucorrhoeal secretion ceases in the 



Fig. 113 




Uterus from a patient dying on the tenth day from a mixed infection — streptococcus and 

colon bacilli. (Jewett.) 

latter half of pregnancy when the decidua reflexa and vera unite. 
Decidual endometritis may arise previous to pregnancy and is one 
of the potent causes of abortion. (See Plate XXXVIII.) 

7. Puerperal endometritis occurs in the puerperium as the result 
of instrumental or digital infection. It is not infrequently of gonor- 
rhoeal origin. 

8. Postabortive endometritis follows abortions usually as the result 
of instrumental or digital infection. 






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ENDOMETRITIS 



289 



9. Exfoliative endometritis (membranous dysmenorrhoea) is re- 
cognized clinically by the periodic expulsion of a membrane from 
the uterus, either as a cast of the uterus or in the form of shreds. 
Expulsion of the membrane is accompanied by severe pain. For 
differentiation of this variety from other discharged membranes 
see page 146. 



Fig. 114 




uterus from patient dying on tenth day from a pure streptococcic infection. (Jewett.) 



10. Senile endometritis, as the name implies, occurs in ad- 
vanced years, and in its clinical manifestations (hemorrhage, leu- 
corrhoea, and pain) may very closely simulate carcinoma. There 
is no satisfactory explanation of the etiology of senile endome- 
tritis. 

While the above forms are commonly recognized without diffi- 
culty, there is a minority of cases in which endometritis is only 
distinguished by anatomical (gross and microscopic) observations. 



290 SPECIAL DIAGNOSIS 

It is evident that an additional classification based upon anatomical 
findings will serve where the clinical signs fail. 

B. ANATOMICAL CLASSIFICATION OF ENDOMETRITIS. 

A variety of forms of endometritis is recognized by the micro- 
scope and the unaided eye. 

Fig. 115 



A^^/->a^?^\ •- "^^r'*' '■-: "' '^;^ 







,.^^^.4.^" 















Hypertrophic glandular endometritis. The endometrium is thickened, soft, and folded. 
In the cervix are several distended glands, forming a cystic protrusion. 

In hypertrophic glandular endometritis the glands of the endo- 
metrium are greatly increased in size and proportionately irregular 
in outline. They are lined by a single layer of epithelium and 
are separated by a connective-tissue space less than the diameter 
of the gland. 

I. Macroscopic Forms of Endometritis. 

Macroscopic forms of endometritis are diagnosed after the 
uterus is removed and opened. Such findings may be wholly 
unsuspected in the absence of all clinical symptoms of endome- 
tritis. The following forms are recognized by the unaided eye; 



ENDOMETRITIS 



291 



1. Hypertrophic endometritis, in which the endometrium is thick- 
ened and 'Soft. 

2. Fungous endometritis, in which the endometrium is thrown 
into folds and fungosities. 

3. Villous endometritis, in which the surface of the endometrium 
is covered with shaggy villosities. 

4. Polypoid endometritis, in which one or more mucous polyps 
project from the endometrium. 

Fig. 116 






', \. \\ /-, ^J 7 






\ 










^ W'\Hr 



Normal endometrium of a young woman. The surface is covered with a single layer of 
low columnar epithelium. The glands are tubular, wavy, lined with columnar epithelium 
similar to that of the surface, and extend to the musculature. They run almost at right 
angles with the surface of the endometrium. The connective tissue is embryonal in type, 
and contains but few small bloodvessels, difficult to demonstrate. 

5. Ulcerative endometritis, in which true ulcers are formed in 
the endometrium. These ulcers show either a virulent form of 
infection or malignant degeneration. 

6. Pseudodiphtheritic endometritis, following labor and abortion. 
On the surface of the endometrium is a necrotic layer formed 
of fibrin, degenerated epithelium, leukocytes, blood, and micro- 
organisms. 



292 SPECIAL DIAGNOSIS 

II. Microscopic Forms of Endometritis. 

The importance of the microscope in the diagnosis of endometritis 
has been alluded to. The microscope affords the only means of 
making a positive diagnosis of these cases. Without the aid of 
the microscope and relying upon clinical signs and symptoms, 
not only may the diagnosis and prognosis be faulty, but the uterus 
may be sacrificed in the treatment of what appeared to be a malig- 
nant growth. Furthermore, life may be sacrificed from failure to 
remove a malignant growth in which the characteristic symptoms 
were absent or suggestive of endometritis. In order that no serious 
oversight be made, it is important that a systematic microscopic 
examination be made of all uterine scrapings. Two general forms 
of endometritis are recognized by the microscope — the glandular 
and the interstitial. The two forms are very commonly associated. 

1. Glandular endometritis is characterized by an increase in size 
or number, or both, of the glandular elements. The surface of the 
endometrium is thrown into irregular elevations, forming folds, 
fungosities, villi, or polyps. 

By the increase in size and number of the secreting epithelial 
cells the glands become enlarged and irregular in their course. The 
interglandular spaces are decreased proportionately to the increase 
in the glandular elements. The glands which in normal conditions 
rarely penetrate into the musculature will, when hypertrophied, 
penetrate this region to a limited degree. The distortion of the 
glands may be extreme. In longitudinal sections the glands may 
appear to twist like a corkscrew. The inversion and eversion of the 
glandular epithelium may give to the gland a serrated appearance. 

The glands are not only increased in size (hypertrophic glandular 
endometritis), but may be increased in number (hyperplastic gland- 
ular endometritis). The increase in the number of the glands is a 
result of the budding from preformed glands, or of invaginations of 
the surface epithelium. If we fail to satisfactorily classify the 
established forms of endometritis, how much more difficult it is to 
draw the line sharply between inflammatory growths of the endo- 
metrium and true tumor formations. 

Are we to recognize a benign adenoma of the uterus? Are the 
mucous polyps to be classified as new-growths or as polypoid forms 
of endometritis? In short, is it possible to define the so-called 



PLATE XXXIX. 









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I' 



Cystic Hyperplastic Glandular Endometritis. 

E. Surface epithelium. 

C. Cystic space formed from a dilated gland, lined by a single layer of 

columnar epithelium and filled with serum. 

D. Group of small round cells. 

H. Cross-section of a gland lying within the musculature. 

M. Musculature. 

B. Congested bloodvessels. 



ENDOMETRITIS 29 



Q 



hyperplastic glandular endometritis from benign adenoma of the 
endometrium ? 

Referring to general pathology, we are unable to distinguish 
hyperplastic glandular growths of inflammatory origin from benign 
adenomata. In reviewing the opinions of a number of authors it 
becomes evident that to separate the two would be impossible, and 
to admit of a connecting link between the two lesions is admissible. 

Fig. 117 

I ~ y ' \ ' ..•".' ■ ■■ '" - -"'' i 






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t<^ 



0. ^^' o ' ^-^ 



/■■'■ 



Cvy Vv/yH^c \ 



Normal endometrium of a woman in the postclimacteric period. The connective tissue 
is more compact and mature; the glands are small and far separated. 

Rindfleisch, Chiari, Weichselbaum, and Orth favor the view 
of simple inflammatory hyperplasia to the exclusion of benign 
adenoma of mucous surfaces. Thoma, Eppinger, and Ponfick 
recognize adenoma, while others, as Van Heukelom and Birch- 
Hirschfeld, believe in the existence of a connecting link between 
these lesions. x411 believe in the inflammatory origin of mucous 
polyps. Polyps of inflammatory origin are found in the stomach 
by Klebs. Birch-Hirschfeld, Petrow, and Landel describe diffuse 
and circumscribed growths of the gastrointestinal tract due to 
catarrhal inflammation. By a careful analysis of their reports it is 



294 SPECIAL DIAGNOSIS 

evident that inflammatory hyperplasia of mucous surfaces merges 
insensibly into tumor growths both benign and malignant. In a 
large percentage of their cases carcinoma was associated in the same 
organ. In the urinary tract Stoerck, Cahen, Rehn, and Kaufmann 
recognize papillomata of inflammatory origin. 

Le Count says: ''It is especially concerning tumors of the 
Fallopian tube that confusion has arisen; there has been quite a 
general failure to recognize that a diffuse hyperplastic inflammation 
is possible — a process that is strictly analogous to the polypoid 
hyperplasia of other mucous surfaces — and that in certain typical 
examples it is as distinct from tumor growth as gastritis proliferans 
is from carcinoma of the stomach." He believes it to be fully 
demonstrated that there exists an imperceptible transition of hyper- 
plastic processes of the tubal mucosa into those of true tumor 
growths, and that these may terminate in the production of benign 
tumors. 

If, then, there is no unanimity of opinion among general path- 
ologists, it is not surprising that the same discrepancy exists among 
gynecologists in reference to similar lesions in the endometrium. 

We find Pozzi, Olshausen, Doderlein, Gebhard, and Ruge failing 
to recognize benign adenoma of the uterus, and classifying them 
all as inflammatory hyperplasia, reserving the term adenoma for 
malignant glandular growths. 

Herman gives as his reasons for discrediting the inflammatory 
origin of these growths: first, that pus would be secreted if it were 
inflammatory; second, recovery would ensue if it were genuine 
endometritis; third, severe hemorrhage would not occur if it were 
endometritis. He, therefore, speaks of polypoid and hyperplastic 
or diffuse adenoma. The fallacies of his reasonings are too evident 
to demand consideration. 

Landau tells us that the increase in the number of glands can 
only occur in adenomata, and never in endometritis; while Gebhard, 
Ruge, and Doderlein speak of this increase in the number of the 
glands as characteristic of hyperplastic glandular endometritis. 

The conclusion is that the two lesions cannot be clearly differ- 
entiated; that a connecting link exists between them. Practically 
speaking, all are agreed that there exists a tendency on the part 
of inflammatory glandular growths to develop into benign and 
malignant new-growths, and when occurring in old age, or when 



END METRITIS 



295 



recurring after repeated curettage, they are to be regarded with 
suspicion.^ 

Fig. 118 . Fig. 119 



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Fig. 121 



Fig. 122 




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Fig. 123 






Fig. 124 




Fig. 125 



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Explanation of scheme of gland invagination. Figs. 118 to 124 show longitudinal sections 
of invaginated uterine glands; Figs. 119 to 125 show cross-sections of the same gland. The 
glands shown in longitudinal section are crossed each by a line showing the plane at which 
the cross-sections are made. Fig. 118 shows the fundus of a gland invaginated with sec- 
ondary eversion. Fig. 124 shows intraglandular papillary invagination of a gland epithelium 
from the side of the gland. Fig. 120 shows simple invagination of the fundus of a gland. 
Fig. 122 shows the inner and outer segments regular and the middle segment invaginated.^ 

^ Amann. Mikroskopisch-Gynakologischen Diagnostik. 



296 



SPECIAL DIAGNOSIS 



The buds from parent glands may again and again give off new 
glands. We speak of an inverted gland when processes of the gland 
protrude into the lumen; of an everted gland when the processes 
protrude from the lumen. In the inverted gland cross-sections will 
give the appearance of a gland within a gland. (See the schematic 
drawing, page 295.) More or less connective tissue invariably 
separates the glands — a fact to be remembered in differentiating 



Fig. 126 









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Interstitial endometritis. The glands are decreased in size and far separated by 

mature connective tissue. 

this condition from malignant adenoma. In rare instances two 
or more layers of epithelium are found on the surface of the mucosa 
or in the glands. Many layers of squamous epithelium have been 
observed. Such proliferating epithelium is always superficial, never 
passing beyond the basement epithelium, as in malignant glandular 
growths. 






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ENDOMETRITIS ^97 

Spontaneous healing of glandular endometritis is possible though 
not probable. At the time of the menopause the hypertrophied 

Fig. 127 

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glands may diminish in size along with contraction of the intersti- 
tial connective tissue. 



298 SPECIAL DIAGNOSIS 

2. Interstitial endometritis is characterized by a hyperplasia of 
the interglandular connective tissue at the expense of the glandular 
elements. Two stages are recognized — the acute and the chronic. 

a. Acute interstitial endometritis presents a small round- 
cell infiltration in the stroma, which may be diffuse or circum- 
scribed. The bloodvessels are congested and a serous or sero- 
sanguineous exudate permeates the connective-tissue spaces. The 
glands are crowded apart by the widening of the interglandular 
spaces. They are irregularly compressed, causing them to be 
greatly distorted. Healing may be perfect from absorption of the 
exudate, or the acute stage may gradually merge into the chronic. 

Acute senile endometritis is described by Dunning, who presents 
the following summary of the anatomical findings: The endo- 
metrium is thickened, the free surface is devoid of an epithelial 
covering; there is an increase in the vascularity with a peculiar 
arrangement of the small bloodvessels; there is a small round-cell 
infiltration; the glandular elements are diminished; the coats of 
the arteries of the muscularis are degenerated. The presence of 
diseased appendages in both cases reported by Dunning and of a 
mild form of pelvic peritonitis in one case seems to indicate that 
the inflammation tends to extend beyond the limits of the uterus. 

h. Chronic Interstitial Endometritis. Newly formed con- 
nective tissue separates the glands. The glands are irregularly 
compressed and may suffer pressure atrophy. In place of the 
embryonal connective tissue normally found in the endometrium, 
there is matured fibrous tissue which first thickens the endometrium 
and later contracts, resulting in the diffuse or localized atrophy of 
the mucosa. The surface of the endometrium becomes irregular. 
Retention cysts may appear in the endometrium from an obstruc- 
tion at the outlet of the glands, causing the glands to distend with 
the secretions. In direct proportion to the distention of the glands, 
the epithelial cells lining them are compressed and may be quite 
flattened. The interglandular spaces may be greatly narrowed. 
When retention cysts are numerous the term cystic glandular endo- 
metritis or cystic interstitial endometritis is applied. 

When the connective-tissue spaces are filled and distended by a 
serous or serosanguineous exudate, the term exudative interstitial 
endometritis is applied. Thus, there may be a combination of these 
forms, and one may speak of a hypertrophic and hyperplastic 



ENDOMETRtTIS 299 

cystic, exudative, glandular, and interstitial endometritis — a rather 
formidable name, but nevertheless suggestive. 

Combinations of the glandular and interstitial forms of endo- 
metritis are the rule. It is unusual for either form to exist alone. 
Rarely are the glandular and interglandular tissues uniformly 
involved (diffuse endometritis). 

The diagnosis of uterine scrapings in endometritis is pre- 
eminently satisfactory and reliable. The loose texture of the endo- 
metrium permits easy removal of the mucosa by the sharp curette. 
It is true that the structures composing the mucosa are more or less 
distorted in the scrapings, and that the deep layers of the endo- 
metrium are seldom found in the removed particles. When we 
consider that the upper strata may show glandular changes and the 
lower, interstitial changes or the upper strata show an inflammatory 
reaction and the lower malignant degeneration, it is evident that 
the microscopic examination of scrapings is not always reliable. 

Little can be definitely learned from the naked-eye appearance 
of the scrapings. Large, friable masses, homogeneous in appear- 
ance, of a pale-gray color, suggest malignancy. In cystic formations 
the open spaces may be detected by the naked eye. In general, it 
may be said that little that is positive can be learned from a macro- 
scopic examination of particles removed from the uterus by the 
curette. Ruge says: '^Die Menge des Ausgekratzen, sei sie gering, 
sei sie reichlich, giebt neimals, fur sich schon einer sicheren Anhalt fur 
die Entscheidung J obwerklich malign oder oh nur benign."^ 

ENDOCERVICITIS (ENDOMETRITIS CERVICALIS). 

Endocervicitis is an inflammatory lesion confined to the cervical 
canal. Part or all of the cervical endometrium may be involved, 
the extent of the lesion varying from a mere inflammatory zone 
about the external os to a diffuse inflammation of the entire surface, 
extending above the internal os and below the external. 

The diagnosis should not be diflBcult, because of the accessibility 
of the lesion to direct inspection and exploration. The color of 
the inflamed mucosa varies from a bright red to a dull cyanotic 
hue. The surface may be smooth, but is more often granular or 

^ Winter's Gynakologische Diagnostik. 



300 



SPECIAL DIAGNOSIS 



papillary. The arbor vitcne are rounded and partially obliterated. 
By touching the surface with the finger or sound slight bleeding 
may be excited, and it is even possible for spontaneous bleeding 
to occur. Tenacious, glairy mucus covers the surface and may 
effectually plug the cervical canal. The mucus accumulating 
within the cervical canal may cause pressure atrophy of the 
mucosa, and thus dilate the canal. The secretion may be clear, 



Fig. 128 




Mucous polyp of the cervix, showing transformation of the columnar epithelium into 
stratified squamous epithelium. This condition may be mistaken for malignant degener- 
ation. 



transparent mucus or may be milky from the addition of leukocytes 
and epithelium. 

Mucous polyps of inflammatory origin protrude from the mucosa 
into the cervical canal and out through the external os into the 
vagina (Fig. 128). 

Microscopic examination of scrapings from the cervix is unsatis- 
factory, for the reason that the surface epithelium and glands are 
firmly embedded in connective tissue and are not readily scraped 



PLATE XLl, 




Erosions of Cervix. 



1. Follicular Erosion. 

2. Follicular Erosion. 



3. Mucous Polyp of Cervix 

4. Papillary Erosion. 



ENDOMETRITIS 301 

away, as, is the endometrium of the uterine body. As in endome- 
tritis, we find in the cervix two microscopic forms — the glandular 
and interstitial. 

EROSIONS OF THE CERVK. 

1. Simple. 

2. Papillary. 

3. Follicular. 

An erosion of the vaginal portion of the cervix is a mucous patch 
consisting of a layer of columnar epithelium and newly formed 
glands lying beyond the external os and replacing squamous strati- 
fied epithelium. Formerly erosions of the cervix were believed to 
be true ulcers, and were vulgarly called "ulcers of the womb." 
We are indebted to Ruge and Veit for the demonstration of their 
true character. The red or bluish color of the mucous patch is 
in marked contrast to the surrounding pale and smooth vaginal 
epithelium. The margins are irregular but sharply circumscribed. 
The extent of the lesion is variable. In nulliparae there is usually 
a mere zone about the external os, while in multiparse the erosion 
may extend far up upon the vaginal portion of the cervix and even 
to the vault of the vagina. Isolated patches may be seen on the 
vaginal portion of the cervix, with normal vaginal epithelium inter- 
vening. 

Classification. Erosions may be classified as simple, papillary, 
and follicular. 

1. A simple erosion has a smooth surface covered with a single 
layer of columnar epithelium. Newly formed glands may dip into 
the underlying connective tissue. 

2. A papillary erosion, as the name implies, presents a papillary 
surface. In addition to the surface layer of columnar epithelium 
there are deep invaginations in the form of glands alternating with 
elevations composed of new-formed connective-tissue and round 
cells. The new-formed cells vary greatly in number and size 
and secrete abundant mucus. The papillary elevations are in direct 
proportion to the connective-tissue hyperplasia and round-cell 
infiltration. 

3. A follicular erosion is characterized by the presence of reten- 
tion cysts, the so-called ''Nabothian follicles." These retention 
cysts arise from the occlusion of the mouths of the new-formed 



302 



SPECIAL DIAGNOSIS 



glands in the erosion. They are filled with inspissated mucus. 
To the touch of the examining finger they are likened to the feeling 
of shot under the skin; to the eye they appear as rounded eleva- 



FiG. 129 









Transition of squamous epithelium of vaginal portion of columnar epithelium of the cervical 

canal. (Abel.) 

tions of a gray, blue, or yellow color. In number they range from 
one to a score or more, and may attain the size of a hen's egg, 



Fig. 130 




, ..'•.•-:;-:;.<i-x.-.!;-:.i ^J' 






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-O' 



^v-^'-^-- 



y 



I'-'-iii. 






Papillary erosion of the cervix. The squamous epithelium has been partially replaced by 
columnar epithelium. The surface is uneven and papillary. The tissue is deeply infiltrated 
with small round cells, and new glands are formed by the invagination of the surface 
epithelium. 

though it is unusual for them to distend to a size larger than a 
hazelnut. The epithelium lining the cyst becomes flattened and 
may be entirely lost. 



PLATE XLII. 




Erosions of Cervix. 

1. Hyperaemia of Cervix. 3 Papillary Erosion. 

2. Simple Erosion. 4. Simple Erosion with Stellate Laceration. 



END OMETR IT IS 



303 



The Healing of Erosions. We speak of incomplete and of complete 
healing of erosions. By this is meant the replacing of the mucous 
patch with squamous epitheHum. 

In complete healing of an erosion the surface epitheUum and the 
glands of the erosion are completely replaced by squamous epithe- 
Hum, thereby restoring the vaginal portion of the epithehum to its 
normal integrity. 

In incomplete healing of an erosion the columnar epithelium on 
the surface of the erosion is replaced by many layers of squamous 



Fig. 131 















1 






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'.CWfiakii 



-i-j 



Incompletely healed erosion of the cervix. Mucous secreting glands are locked in by 
many layers of squamous epithelium. Formerly the surface was covered by a layer of 
columnar epithelium from which the glands dipped into the connective tissue. The surface 
epithelium became transformed into stratified squamous epitheUum and the glands were 
buried beneath. 



epithelium similar to that of the surrounding vaginal mucosa. 
The glands beneath are not obliterated, but are either locked in 
beneath the squamous epithelium or open directly upon the surface 
now covered with squamous epithelium. 

Healing of an erosion is effected by metaplasia of the cylin- 
drical epithelium into many layers of squamous epithelium. (See 
Fig. 132.) 

Differential Diagnosis of Endocervicitis. A clinical diagnosis 
of endocervicitis is commonly made from the mucous or mucopuru- 



304 SPECIAL DIAGNOSIS 

lent secretion coming from the cervix. It is well to discriminate 
between a hypersecretion of the cervix due to passive congestion 
and a secretion which is the expression of an infection. This, 
however, is not always possible. A mucous secretion seen to leave 
the cervical canal must necessarily come from the cervix, there 
being no mucus in the secretion of the uterine body or Fallopian 
tubes. When pus is mixed with the mucus, there can be no doubt 
as to the infectious origin of the secretion. 



Fig. 132 




i\"--:^ 




■ **'.^^. • ' '.-■', v» vr,v»'"y' ■ • l^'..•."•;,a,w^- 










Incomplete healing of an erosion of the cervix. Between two sections of stratified 
squamous epithelium is a limited amount of columnar epithelium which is invaginated in the 
form of irregular glands. Numerous glands are locked in beneath the squan\ous epithelium. 

In this case the surface was originally smooth and covered with stratified squamous epi- 
thelium; the squamous epithelium became destroyed and replaced by a single layer of 
columnar epithelium, from which glands were formed. Subsequently, through a healing 
process, part of the surface epithelium was transformed into stratified squamous epithelium 
and the glands were covered over, as seen above. 

. Erosions of the cervix may closely simulate carcinoma. The 
macroscopic appearance may be identical. The differential diag- 
nosis is given in Chapter XXVIII. (See Plates XLL, XLII., and 
XLIII.) 

Ectropion of the lips of the cervix may closely resemble erosions. 
If the lips of the cervix are grasped by tenacula and approximated, 
the reddened surface will roll into the cervical canal and disappear. 
If an erosion is present, there will be no disappearance of the red- 
dened zone. 



ENDOMETRITIS 305 

ULCERS OF THE CERVIX. 

True ulcers of the cervix are of rare occurrence. Formerly 
erosions were regarded as such. 

Decubitus ulcers of the cervix are found in prolapsus of the 
uterus and as the result of ill-fitting pessaries. Such ulcers may 
attain the size of a silver dollar. They are usually superficial with 
irregular outlines ; the margins are not elevated'', the base is granular, 
firm, and covered by a grayish-yellow secretion. The tendency to 
bleed is not great, as compared with malignant ulcers. Further- 
more, in contrast with carcinoma, there is a marked tendency to 
cicatrization. Under the microscope the epithelium is seen to be 
lost. The base is thickly beset with distended capillaries embedded 
in the meshes of connective tissue and small round cells. This 
round-cell infiltration extends a variable distance into the under- 
lying connective tissue. A structureless, necrotic material may 
collect upon the base of the ulcer. 

Tuberculous ulcers will be described below. 

Cancerous Ulcers. (See Chapter XXVIII.) 

TUBERCULOSIS OF THE CERVIX. 

Tuberculosis of the cervix, as a primary lesion, is a rare finding. 
Beyea finds sixty-eight cases of primary tuberculosis of the cervix 
in the literature, and adds a single case. In nine of these cases 
the lesion was confined to the cervix; in the balance there was an 
invasion of adjacent structures. The greatest number occurred 
between the ages of twenty-one and forty years; the extreme ages 
were seventeen and seventy-nine. 

Beyea divides the pathological forms into the ulcerative, hyper- 
plastic, and miliary. 

Tuberculous ulcers of the cervix may follow primary tuberculous 
infection of the endometrium ; or, as is more often the case, a primary 
infection of the tubes, with subsequent extension downward to the 
uterus and cervix. The diagnosis must be based upon the finding 
of giant cells, tubercles, and of tubercle bacilli in and about the 
ulcers. The margins of a typical tuberculous ulcer are irregular 
and undermined; the base of the ulcer is uneven and tends to heal 
by cicatrization. 

20 



306 SPECIAL DIAGNOSIS 

Miliary tuberculosis of the cervix has been recognized but three 
times. 

In general, it may be said that tuberculosis of the cervix closely 
resembles erosions and cancers. A positive diagnosis can only be 
made by the aid of the microscope. The clinical history and the 
finding of tuberculosis elsewhere in the body, particularly in the 
upper genital tract, is of importance in the consideration. 

CHRONIC METRITIS. 

Endometritis can scarcely exist without more or less involvement 
of the uterine musculature. In acute affections the muscularis is 
congested, and the connective-tissue spaces are filled with a serous 
exudate and a round-cell infiltration. Abscesses may develop in 
the connective-tissue spaces and infected thrombi may form in the 
blood spaces. 

In the chronic stage there is a development of connective tissue 
between the muscle fibres. As the connective tissue forms and 
contracts the muscle fibres atrophy, and through this process the 
uterus becomes very firm. 

The diagnosis is based upon the uniform enlargement of the 
uterus and upon the change in its consistency. In the chronic stage 
there may be no tenderness on pressure. 

Chronic metritis may be regarded as a clinical term signifying 
a uterus that is uniformly enlarged, firm in consistency, and one 
which has lost its normal flexibility. 

Chronic metritis is to be diagnosed from interstitial fibroids. 
(See Chapter XXVII.) 

ABSCESS OF THE UTERUS. 

Von Franque {Cent. j. Gyn., No. 20, 1902) reported 15 cases 
of undoubted abscess of the uterus, and Lea (Journal of Obstetrics 
and Gynecology of the British Empire, February, 1904) has added 
another case. The clinical diagnosis is of course diflScult. There 
is no way of distinguishing the condition from a suppurating inter- 
stitial fibroid. In all cases there is a history of puerperal, post- 
abortive or gonorrhoeal infection. Pyrexia will depend upon the 
acuteness and virulence of the infection as will also leukocytosis. 




licular Er'osion ol Uervix 
i , 1 t1 1^ Rful \' nf the. \ 



ENDOMETRITIS 307 

Pain is usually severe and paroxysmal and is referred to the uterus. 
On physical examination the uterus is enlarged; this enlargement 
is not always symmetrical, especially if the abscess is large and 
near the peritoneal surface of the uterus. The uterus may or may 
not be freely movable, is always sensitive to pressure, and its con- 
sistency is variable. Associated inflammatory lesions are invariably 
present. These cases usually terminate in perforation of the uterine 
wall into the peritoneal cavity, uterine cavity, or rectum. 



CHAPTEE XXVII. 

THE DIAGNOSIS OF FIBROMYOMA OF THE UTERUS. 

Etiology. 
Histogenesis. 
Anatomical Diagnosis. 
Microscopic Diagnosis. 
Degeneration of Fibroids. 
Clinical Characteristics. 
Clinical Diagnosis. 
Differential Diagnosis. 

We know nothing of the essential cause of uterine fibroids. 
Certain factors are known to influence their origin and devel- 
opment, and may be briefly discussed. 

1. Heredity has been much referred to as a predisposing cause. 
While there are families in which two or more members are known 
to have fibroid tumors of the uterus, the influence of heredity is 
not to be overestimated. Engstrom, in 530 cases of uterine fibroids, 
found a similar lesion in the mother or sisters thirteen times. It 
has been stated that myomatous patients come of large families. In 
the experience of Roger Williams they averaged 8.1 members each. 

2. Age. The usual time of occurrence is during the period of 
sexual maturity. Fibroids of the uterus are rarely found before 
puberty, though it is highly probable that most, if not all, of these 
growths are of congenital origin. They are most frequent between 
the ages of thirty and forty and are rarely known to arise after the 
menopause. Miller reported 299 cases of uterine fibroids, of 
which number 120 were observed after forty-five years of age. Of 
the 1762 cases collected by Roger Williams 26 were under twenty 
years of age. Gusserow reported one case ten years of age. Pick 
described a fibroid of congenital origin. Cavaillou reports one 
weighing 3 kilograms in an infant three years of age. At the 
other extreme of life is a submucous myoma at ninety-two years of 
age (Van Rensselaer) and a calcified myoma at eighty-six (Wright). 

( 308 ) 



DIAGNOSIS OF FIBBOMYOMA OF THE UTERUS 309 

It is evident from the study of statistics that fibromyomata are 
prone to arise at a time when the sexual functions are waning. 

3. Civil State. It has been stated that fibroids of the uterus are 
especially liable to occur in women who have not borne children 
and are not married. The number of children born to myomatous 
women is below the average, while abortions are relatively common 
among them. The average number of children born of myomatous 
women is estimated at 2.5, as compared with the usual number of 
4.5. Thirty per cent, of myomatous women are sterile as opposed 
to 10 per cent, of sterility in general. On the other hand, sexual 
excesses are said to favor the growth of uterine myomata. 

4. Race. The negress is generally regarded as pre-eminently 
susceptible to uterine fibroids. This is denied by Kelly and 
Williams, of Johns Hopkins, where there is abundant opportunity 
to make reliable observations. In 357 cases reported by Williams 
fibroids were only 2 per cent, more frequent in the colored race. 
They are said to be unknown among savages. 

5. Frequency. Boyle holds that 20 per cent, of women who reach 
thirty-five years of age have fibroids of the uterus, while Klobs 
affirms that 40 per cent, of women who reach fifty years of age 
have fibroids of varying size and number. The lesion is often 
overlooked even in postmortem examinations. Of all non- 
malignant tumors uterine myomata are by far the most common. 
Roger Williams estimates that 10 per cent, of all tumors in women 
are uterine fibroids. 

In Veit's Handbuch we read: "So far as the common myomata 
(excluding the adenomyomata) are concerned, I hold that their 
origin from an embryonic inclusion has not been proven. It appears 
however, that heredity plays a role therein; and one is also able to 
understand that irritation, acting chronically upon the uterus, may 
give rise to the formation of myomata, but the modus operandi of 
the latter is not yet clearly proven." 



INFLUENCE OF MENSTRUATION, PREGNANCY, AND CLIMAC- 
TERIC UPON FIBROMYOMATA. 

1. Menstruation is accompanied by a slight enlargement and soft- 
ening of uterine fibroids due to increased vascularization. Near the 
end of the menstrual flow the tumor assumes its normal proportions. 



310 SPECIAL DIAGNOSIS 

2. Pregnancy is accompanied by a rapid increase in the size of 
the tumor. There is a corresponding softening of the growth. 
Such rapidly growing fibroids are prone to become incarcerated 
and seriously interfere with pregnancy. Simultaneous with the 
involution of the uterus in the puerperium there is sometimes a 
rapid decrease in the size of the tumor. They are even said to 
wholly disappear, though this is doubtful. However, they are some- 
times reduced in size by the end of the puerperium. The rule is that 
they are not reduced in size, but on the contrary continue to grow 
after the climacteric and tend to degenerative changes and extrusion. 

3. The climacteric is generally credited with having a favorable 
influence upon the growth of uterine fibroids, but experience points 
to the reverse. The rule is that they continue to grow and are more 
liable to degenerative changes at this time of life than at any other. 
Progressively growing postclimacteric fibromyomata are plentiful 
in literature. Herman reported one growing thirteen years after 
the menopause. Tait removed one twenty years after the climac- 
teric. Van Rensselaer removed a submucous myoma from a woman 
ninety-two years of age. 

HISTOGENESIS OF FIBROMYOMA OF THE UTERUS. 

According to Kleinw^achter, fibroids originate from round cells 
found in bloodvessels, which later become obliterated. The round 
cells are converted into muscle and connective-tissue fibres. Rosger 
believes their origin to be in the muscle fibre of bloodvessels. Gott- 
schalk is of the opinion that it is not the musculature of the blood- 
vessels that forms the matrix of the tumor. He observed amoebic 
movements in certain protoplasmic bodies which he interpreted to 
be parasites, and believed them to be the essential cause of fibroids. 
Vedeler believed he discovered animal parasites in uterine fibroids. 
Virchow believed them to be a hyperplasia of the uterine muscula- 
ture. Judging from the above conflicting opinions, it is evident that 
nothing is certainly known of the histogenesis of uterine fibroids. 

THE ANATOMICAL DIAGNOSIS OF UTERINE FIBROIDS. 

Under this head we will consider the size, form, consistency, rate 
of growth, number, and position of the tumor, and also the micro- 
scopic structure. 



DIAGNOSIS OF FIBROMYOMA OF THE UTERUS 311 

In size uterine fibroids vary from almost microscopic dimensions 
to the tumor reported by Hunter, weighing 140 pounds and that of 
Severann weighing 195 pounds. Webster recently reported a fibro- 
cystic tumor of the uterus weighing 87 pounds. Recovery followed 
the operation, which was almost wholly performed under local 

Fig, 133 







Multiple uterine fibroids. The uterine canal is distorted by two large interstitial fibroids 
— a pedunculated and a senile fibroid occupies the surface of the uterus, and on the opposite 
(right) side is a small subperitoneal fibroid. (Specimen removed by Dr. J. Clarence Webster.) 



anaesthesia. So far as I am able to find in the records this is the 
largest uterine fibroid to be removed successfully. Adhesions 
nearly always complicate these large tumors. 

The form is smooth and rounded, or, as is more often the case, 
nodular. 

In consistency fibroids vary from soft and semifluctuating to a 



312 SPECIAL DIAGNOSIS 

stone-like hardness. Fibroids are classified as hard and soft. 
Hard fibroids consist largely of fibrous tissue with a relatively 
small amount of muscle fibre; the blood supply is not great. Soft 
fibroids are made up of a relatively large amount of muscle tissue 
and are very vascular. 

The rate of groivth of soft fibroids is more rapid than that of 
hard fibroids. During pregnancy fibroids grow rapidly. After the 
menopause they usually decrease in size, though the menopause is 
often delayed three to ten years. They are seen to grow with 
surprising rapidity when undergoing myxomatous degeneration. 
Scholer estimates that fibroids are seldom appreciable in less than 
a year; that in five years they may attain to the size of a man's fist, 
and in thirteen years to the size of a man's head. However, it is 
not possible to estimate the age of a tumor by its size. This fact is 
demonstrated by the many small fibroids which are known to be 
thirty and forty years of age — " latent fibroids." 

It is exceptional for fibroids to exist singly. As many as 400 
separate and distinct tumors have existed in the uterus. We speak 
of fibroids as single or multiple. 

According to Martin, the tendency to multiplication increases 
with the age of the patient. 

The position of fibroids in relation to the uterine wall is of the 
greatest clinical importance. The terms submucous, intramural or 
interstitial, and subserous or subperitoneal are used to designate 
the location of the tumor. All fibroids are originally intramural, 
and as they increase in size they tend to grow in the direction of 
least resistance. For example, an intramural fibroid lying nearer 
the endometrium than the perimetrium will eventually become sub- 
mucous. So long as a fibroid is completely enveloped by the 
musculature, no matter to what extent, it is intramural, but when 
the capsule of the fibroid is immediately covered with peritoneum 
or mucosa it becomes subperitoneal or submucous. When the 
growth sits upon the inner or outer surface of the uterus with a 
broad base, it is known as a sessile growth; when the base of attach- 
ment is constricted, it is known as a pedunculated growth. The 
more pedunculated the tumor the slower the growth, because of 
the limited blood supply passing through the pedicle. The pedicle 
when long may so limit the blood supply to the tumor that atrophy 
will result. Twisting of the pedicle may completely interrupt the 



DIAGNOSIS OF FtBROMYOMA OF THE UTERUS 



313 



blood supply, in which case the fibroid will become gangrenous. 
If the tumor is adherent to neighboring structures, a requisite supply 
may be conveyed by the adhesions. A partial twist of the pedicle 
may be followed by atrophy or oedema of the tumor. 



Fig. 134 




Submucous fibroid of the uterus. The tumor is attached to the posterior wall of the 
uterus by a broad base. The overlying mucous membrane is atrophied. This atrophy of 
the endometrium accounts for the absence of hemorrhage. 

Spontaneous amputation of the tumor by lengthening or twisting 
of the pedicle is one of nature's means of effecting a cure in sub- 
mucous growths. 



314 



SPECIAL DIAGNOSIS 



Fibromyomata of the cervix occur in about 6 per cent, of all 
uterine fibromyomata. 

1. Submucous fibromyomata bulge into the uterine cavity and 
are directly covered with mucous membrane. They are either 
pedunculated or sessile, single or multiple, and are seldom as large 
as the patient's head. The pedicle may permit them to protrude 
into the cervical canal or farther on into the vagina. They usually 
possess a relatively large amount of muscle fibre and bloodvessels, 



Fig. 135 




Submucous fibroid of the uterus. The uterus is evenly distended by a large fibroid. 



and hence are soft in consistency, and their growth is rapid. When 
large and soft their form is moulded to that of the uterine cavity. 
They are rarely spherical, but more often elongated. The cervix 
may constrict them into an hour-glass shape. As the tumor in- 
creases in size the overlying mucosa may be atrophied ; likewise, the 
opposing mucosa of the uterus may suffer pressure atrophy, and 
adhesions may form between the tumor and uterine mucosa. This 



DIAGNOSIS OF FIBBOMYOMA OF THE UTEBUS 315 

explains the absence of hemorrhage in many of the large submucous 
fibroids. Leyden and Kiister described a case in which a fibro- 
myorna having become detached from the uterus adhered firmly 

Fig. 136 




Pedunculated submucous fibroid protruding through the cervix. The fibroid protrudes 
from the cervix as a firm, rounded tumor with a smooth vascular surface. The tumor is 
attached by a pedicle to the body of the uterus. It is possible for such a growth to be 
detached and spontaneously expelled. (Specimen removed by Dr. J. Clarence Webster.) 



to the cervix. Partial inversion of the uterus may be caused by 
traction upon the fundus by a pedunculated submucous fibroid 



316 SPECIAL DIAGNOSIS 

attached to the fundus. The effort on the part of the uterus to 
expel the fibroid causes the inversion. 

2. Interstitial fibromyomata he encapsulated within the uterine 
wall. Rarely are these growths ill-defined from the uterine muscula- 
ture (diffuse fibromyomata). When large the growth bulges upon 
the mucous or serous surface or upon both surfaces. Such growths 
are usually multiple and are seldom so firm in consistency as are 
subserous growths. 

3. Subserous fibromyomata bulge upon the serous surface of the 
uterus. They are single or multiple, commonly firm in consistency, 
though sometimes soft and apparently fluctuating. When pedun- 
culated they may be freely movable or firmly fixed by adhesions 
which bind the growth to surrounding structures. When located at 
the side of the uterus the growth may develop between the layers of 
the broad ligament — ''intraligamentary or broad ligament fibroids." 

Fibroids of the cervix may be submucous, interstitial, or sub- 
serous (subvaginal). Submucous fibroids of the cervix are seldom 
large. They are usually pedunculated, and as such are known as 
fibrous polyps. 

Interstitial fibroids of the cervix distort the cervical canal, and 
may cause complete obstruction, locking in secretions above and 
preventing conception. 

Subserous fibroids of the cervix are very rare, and are seldom 
of large size. They may grow into the vagina or into the para- 
vaginal connective tissue. About 10 per cent, of uterine fibroids 
are of the cervix, the balance arise from the uterine body. 

Cervical fibroids are poor in muscular elements and hence are 
firm and slow in growth. They are prone to undergo cystic degen- 
eration and rarely become calcareous. As they increase in size the 
cervix becomes elongated and distorted. Amann described a cer- 
vical fibroid weighing twenty-five pounds. Such large fibroids 
elevate the uterus out of the pelvis. 

On cross-section of a flbromyoma bands of fibrous and muscular 
tissue are seen running in various directions and forming whorls, 
concentric rings, and wavy lines. The color varies from gray to 
a rosy hue, depending upon the relative amounts of fibrous and 
muscular tissue and upon the blood supply. 

Latent Fibroids, On cross-section uteri are frequently seen to 
contain numerous small bodies resembling knots of wood. Such 



DIAGNOSIS OF FIBROMYOMA OF THE UTERUS 



317 



growths are termed ''latent fibroids" by Bland Sutton. Their 
whiteness is in marked contrast to the redness of the musculature. 
In histological structure they are identical to large fibroids. 
Undoubtedly a large number of fibroids never develop beyond 
this stage. Pregnancy exercises a quickening influence upon 
these latent growths. 

RECURRENCE OF UTERINE FIBROIDS. 

The so-called ''recurrent fibroids" referred to by older writers 
are undoubtedly accounted for by the recurrence of what was an 
unrecognized malignant growth, and secondly by the development 

Fig. 137 




Subperitoneal fibroid of the uterus. The uterus is crowded backward by a fibroid 

attached to its anterior wall. 



of fibroids which were overlooked. Malignant growths are known 
to start from the stump of an amputated fibroid. This may be 
called traumatic malignancy, and is not peculiar to fibroids. 



318 SPECIAL DIAGNOSIS 

THE MICROSCOPIC DIAGNOSIS OF FIBROIDS OF THE 

UTERUS. 

The microscopic diagnosis is based upon the finding of mature 
connective tissue and muscle fibres. Without a knowledge of the 
gross appearance of the tumor it is impossible to distinguish a 
fibroid from the uterine wall. The relative amount of connective 
tissue and muscle fibres varies widely. 

A pure fibroid does not exist. There is always present more or less 
muscular tissue. As age advances the connective tissue increases 
at the expense of the muscular elements. The muscle fibres are 
involuntary, and contain spindle-formed nuclei. The cell proto- 
plasm is homogeneous, rarely granular. On cross-section the 
nucleus is half-moon shape. Some fibres contain two or more 
nuclei. Karyokinetic figures are seldom seen in the muscle cells 
of the slow developing growths, but are present in proportion to 
the rapidity of the growth. The connective tissue usually forms 
a loose texture, poor in nuclei. In other growths and in other 
fields of the same growths the connective tissue may be more com- 
pact and contain round or oval nuclei. 

Bloodvessels course through the connective tissue. Veins are 
not as numerous as arteries, particularly in old fibromyomata. A 
central artery running an irregular course through the centre of 
the fibroid is described by Gottschalk, but has not been generally 
recognized. Lorey and Hertz have described nerve fibres in fibro- 
myomata. 

ADENOFIBROMYOMA UTERI. 

Fibroids containing glands are described by numerous authorities. 
Schroeder believes the glands originate in the endometrium. Carl 
Ruge, Gottschalk, Kossman, and others maintain that they arise 
from Gartner's ducts. Recklinghausen contends that the glands 
arise from the Wolffian body or from the endometrium. These 
peculiar growths are almost invariably intramural. They never 
possess a capsule, and are known as diffuse or infiltrating fibroids. 
They are found in the tube, the uterine horn, and occasionally in 
the posterior wall of the uterus. 

In 700 cases of uterine fibroids operated in Johns Hopkins 
Hospital, Cullen reports 19 to be adenofibromata. 



DIAGNOSIS OF FIBROMYOMA OF THE UTERUS 319 

Gebhard gives the following varieties: 

1. A hard form in which the muscle tissue predominates over 
the glandular elements. 

Fig. 138 






Ain 









cm 



Schematic drawing representing the development of uterine fibroids and their relation 
to the uterine wall. (Suggested by Fehling.) 

AI, All, AIII, subperitoneal fibroids. BI, BII, Bill, interstitial fibroids. 
CI, CII, cm, submucous fibroids. 



320 SPECIAL DIAGNOSIS 

2. A cystic tumor with many large spaces. 

3. A soft form in which the glandular elements predominate 
over the fibrous or muscular. 

4. A soft form with widened blood spaces — telangiectatic or 
angiomatous adenomyoma. 

In the growths are often seen small ducts communicating with a 
single large one as the teeth of a comb are joined to its back. These 
ducts are embryonic inclusions of the ducts of the Wolffian body and 
the "uriniere." They may distend into cysts compressing the sur- 
rounding connective tissue. The contents of the cyst are clear and 
serous, occasionally colored by pigment. 

Recklinghausen speaks of pseudoglomeruli in describing eleva- 
tions attached to the cyst wall by a broad base. 

Pick described a submucous adenomyoma averaging 55 grams. 
CuUen reported to the Johns Hopkins Society an adenomyoma of 
the round ligament. 

DEGENERATION OF FIBROIDS. 

Noble {American Gynecology, April, 1903) made a detailed 
report of 258 cases of uterine fibroids with special reference to the 
degenerative changes. In estimating the risks encountered by 
patients suffering from fibroid tumors Noble considers first those 
growing out of the complications themselves, which include those 
causing a fatal result, those threatening life, and those causing 
more or less invalidism. Of the fatal degenerations and complica- 
tions there were 88. Of complications threatening the life of the 
patient there were 37, and of conditions leading to more or less 
invalidism there were 43, thus giving a sum total of 168 serious 
complications in 258 cases of uterine fibroids. Noble presents the 
records of four surgeons, including himself, and estimates that of 
688 cases of uterine fibroids the presumptive mortality without 
operation from the degenerations and complications of the tumors 
and changes taking place in the uterus itself varied as follows: 

Martin .......... 16 per cent. 

Noble 16 " " 

Frederick 23 " " 

Cullingworth 24 " " 

Average 19.75 " " 



DIAGNOSIS OF FIBBOMYOMA OF THE UTERUS 



321 



Adding the complications met with outside the uterus the mor- 
taUty would reach about 45 per cent. Noble concludes that one- 
fourth the cases would result in chronic invalidism and one-third 
in death if no operation is performed. Noble says: *^It seems a 



Fig. 139 




Fibrous polyp of the cervix. The uterus shows senile atrophy together with three small 
subperitoneal fibroids. The polyp is of unusual size. Such polypoid growths are prone 
to arise in a senile uterus. They are frequently the cause of hemorrhage in the post- 
climacteric period. 



fair conclusion that the resort to early operation will effect a saving 
of 25 to 30 per cent, in mortality in addition to the perhaps greater 
saving in the mortality which follows operation as compared with 
that which is incident to the history of fibroid tumors." The 
statistics of Noble, Frederick, Martin, and Cullingworth impress 

21 



322 SPECIAL DIAGNOSIS 

us with the fact that fibroids of the uterus are by no means the 
innocent tumors that former writers would have us beheve. 

The various forms of degeneration of fibroids are not only of 
pathological interest, but their recognition is of the greatest clinical 
importance. 

Noble estimates that serious complications arise in fibroids in 
about one-third of all cases. Of these complications the various 
forms of degeneration constitute a large proportion. 

1. Atrophy. We are familiar with a physiological atrophy of 
fibroids following the climacteric. A similar change takes place 
in event of an artificially induced menopause by the removal of the 
ovaries. In pedunculated tumors the blood supply is limited, and 
as a result atrophy may follow. The wasting diseases exercise a 
staying influence upon the growth of fibromyomata. Atrophy of 
these growths has been observed to follow abdominal sections, 
amputation of the breast, and peritonitis. According to Schroeder, 
this atrophy consists of a fatty degeneration. It is more probably a 
simple atrophy in which the muscle cells diminish in size and in 
number. In this manner large tumors may wholly disappear. 

2. Calcareous degeneration may occur in fibroids of all sizes 
and locations. The calcareous deposits are found in the connective 
tissue, often leaving the muscle fibres isolated and encrusted. 

Gebhard gives the following analysis of the deposit: 

Calc. carb 49.0 

Calc. phosph 29.0 

Calc. sulph 13.0 

Calc. lithat 0.5 

Organic substances .....'... 0.4 

Petrified fibroids are known as **womb stones." It is possible 
for such stones to be severed from the uterus and lie free in the 
peritoneal cavity, or, if submucous, to be either retained in the 
uterus or expelled. Womb stones were described by Hippocrates. 
Everett reported one weighing 2.04 kg. A few weighing 20 pounds 
are reported. Chondrification and ossification have been reported. 
Advanced age predisposes to this condition. 

3. Fatty degeneration of fibroids following pregnancy is of 
common occurrence. The tumor is soft and of a mottled, yellow 
tint. Fat droplets are seen in the muscle fibres. Such a case was 
recently exhibited by Dr. Reuben Peterson before the Chicago 
Gynecological Society. 



DIAGNOSIS OF FIBROMYOMA OF THE UTERUS 



323 



4. Myxomatous degeneration of fibroids is a circumscribed 
degeneration of the connective tissue. Rarely is there a diffuse 
involvement of the tumor. Before cutting into the tumor it may 
appear cystic. On cross-section one or more areas of degeneration 
are seen. The myxomatous material is glairy and translucent, 
containing opaque particles and a fibrillar or fibrous network. By 
absorption of the myxomatous material cystic spaces are formed. 

Fig. 140 




A pedunculated subperitoneal fibroid lies above the promontory of the sacrum and is too 
large to fall into the pelvis. It has drawn the uterus and vagina upward. 



5. Suppuration and gangrene of fibroids is a grave condition, 
demanding immediate surgical interference. The usual cause is 
puerperal infection. Subserous fibroids may be infected through 
the bowel. Twisting of the pedicle of a fibroid may result in 
gangrene. 

6. Amyloid degeneration of a fibroid is described by Stratz. 



324 SPECIAL DIAGNOSIS 

7. Telangiectatic fibroids are of rare occurrence. They are 
formed either from a dilatation of the lymph or blood spaces. The 
tumor is soft and may fluctuate and even pulsate. 

8. Cystic Degeneration. Cysts are found in about 4 per cent, 
of all uterine fibroids. The subperitoneal and particularly the 
pedunculated forms are especially prone to undergo cystic de- 
generation. Sixty-three out of 70 cases collected by Heer were 
subperitoneal. These cysts are usually multiple. Such cysts are 
prone to become infected, in which case the cyst may be converted 
into an abscess. The contents may be discharged into the peri- 
toneal cavity with possible fatal results. All of the largest recorded 
cases of uterine fibroid contain cysts. In the fibrocystic tumor 
reported and operated by Webster, which weighed 87 pounds, the 
fluid contents of the cyst weighed 60 pounds. Peritonitis, hydro- 
peritoneum, intestinal obstruction, and adhesions frequently com- 
plicate these cystic growths. We recognize true cysts with an 
epithelial lining and pseudocysts which are void of . an epithelial 
lining and are formed by the degeneration and absorption of tissue. 
The true cysts arise from epithelial inclusions from the uterine 
mucosa. Wolffian and Mullerian tracts. An endothelial lining 
has been demonstrated by several authorities. The explanation 
for the origin of these endothelial cysts lies in the lymphatic or 
blood canals. 

The contents of myomatous cysts is clear and colorless, bloody, 
purulent, or resembles thick pea soup. 

9. Sarcomatous degeneration of fibroids will be discussed in 
the chapter on Sarcoma of the Uterus. 

10. Cancerous degeneration is an unusual form. The epithe- 
lial elements are derived from the overlying mucosa in submucous 
and interstitial growths or from the glandular elements of an adeno- 
fibroma. But two cases are recorded in which the cancer began in 
the substance of the fibroid. 

CHANGES IN THE ENDOMETRIUM, MYOMETRIUM, TUBES, 

AND OVARIES. 

The endometrium undergoes hyperplastic changes under the irri- 
tating influence of the fibroid. Hence it is that these changes are 
almpst invariably found in submucous, usually in interstitial, and 



DIAGNOSIS OF FIBROMYOMA OF THE UTEBUS 325 

seldom in subperitoneal fibroids. There is hypertrophy and hyper- 
plasia of the elements forming the endometrium. In large fibroids 
bulging into the uterine cavity there may be pressure atrophy of 
the mucosa. When protruding into the vagina the endometrium 
may be transformed into many layers of stratified epithelium, and 
decubitus ulcers may form upon the surface. 

The myometrium becomes hypertrophied. This is particularly 
true of submucous and interstitial growths. The hypertrophy is 
usually proportionate to the size and number of the tumors. 
Champneys described a case which caused such atrophy of the 
uterus as to render the musculature scarcely recognizable. 

The tubes and ovaries share in the hypertrophy to a limited 
extent. It is estimated that the tubes are diseased in 10 per cent, 
of all cases. The tubes are especially liable to be infected in the 
presence of infected and sloughing fibroids. 

CLINICAL CHARACTERISTICS OF FIBROIDS. 

1. Shape. A fibroid grows concentrically, and hence is usually 
round. The firm, subserous tumors, which, from their location are 
less influenced by the uterus, are round or oval. Submucous fibroids 
of softer consistency are moulded by the uterus. When forced 
through the cervix they become elongated and even hour-glass 
shaped. Interstitial fibroids confined within the uterine wall are 
round. 

2. Mobility. Only pedunculated submucous and subserous 
fibroids move independently of the uterus. Broad ligament fibroids 
are restricted in their movements. Fixation by adhesions and by 
incarceration restricts the movements of the tumor and the uterus 
to which it is attached. 

3. Consistency. The consistency of a fibroid varies from a stone- 
like hardness to the softness of a pregnant uterus, and may even 
appear to fluctuate. This variation in consistency is largely to be 
accounted for by the relative proportions of fibrous and muscular 
tissue comprising the growth. The more fibrous the tissue the 
harder the growth. The forms of degeneration causing a hardening 
of the growth are atrophy (so-called fibroid degeneration), calcareous, 
cartilaginous, and osteomatous degeneration; those causing a soften- 
ing of the fibroid are fatty, myxomatous, cystic, oedematous, puru- 



326 SPECIAL DIAGNOSIS 

lent, gangrenous, telangiectatic, sarcomatous, and cancerous degen- 
eration. During pregnancy the tumor softens and grows rapidly; 
after pregnancy it becomes smaller and firmer. 

During the period of menstrual congestion the growth increases 
slightly in size and is more elastic. 

4. Rate of Growth. The softer and more vascular the tumor 
the more rapid its growth. It is important to observe the rate of 
growth in distinguishing a growing fibroid from a pregnant uterus 
and in determining malignant degeneration. 

CLINICAL DIAGNOSIS OF UTERINE FIBROIDS. 

The diagnosis of uterine fibroids rests largely upon the local find- 
ings. Symptoms at best are only suggestive of their possible presence. 

Subjective Signs. Two general groups of symptoms are to be 
considered: those due to hemorrhage, and those due to pressure 
and traction made by the growing tumor. 

1. Hemorrhage in the form of an increase of the menstrual flow 
is usually the first event that attracts the attention of the patient. 
An excessive menstrual flow beginning late in the childbearing 
period and associated with dysmenorrhoea should suggest the 
probable presence of a uterine fibroid. As time goes on the loss 
of blood may seriously undermine the patient's health, and has 
been known to cause death. There may be no intermission, or 
intervals of variable length may be interrupted by profuse and 
even alarming hemorrhages. It is seldom that the loss of blood 
is distinctly and exclusively intermenstrual. The blood comes 
from the endometrium, rarely from the fibroid. The tumor acts 
as a foreign body irritating the endometrium. Hence it is that 
hemorrhage occurs almost invariably in submucous fibroids, to a 
lesser extent in interstitial, and seldom in subperitoneal fibroids. 
It is possible for a subperitoneal growth to interfere with the cir- 
culation in the uterus and indirectly cause hemorrhage. Mental 
excitement, physical exertion, and instrumental and digital exam- 
inations excite hemorrhage. The blood is often expelled in clots. 
This clotting is partly the result of obstruction to the outflow of 
blood by the tumor and by displacement of the uterus. 

2. Pressure and traction made by the growing tumor upon sur- 
rounding structures are later developments than hemorrhage, and 



DIAGNOSIS OF FIBROMYOMA OF THE UTERUS 327 

are not usually manifest until the tumor has attained considerable 
size. Subperitoneal growths are most likely to produce these 
symptoms. A variety of symptoms arises from direct pressure 
and traction. Pain is caused by pressure of the growing uterus 
and tumor upon the various structures in the pelvis. A fibroid 
incarcerated in the small pelvis may early cause pain even to an 
intolerable degree. ' Intraligamentary fibroids no larger than a man's 
fist may occasion distressing pain. On the other hand, large, freely 
movable fibroids occupying the abdominal cavity may cause no pain. 

The pain is referred to the lumbar and sacral regions, to the 
shoulders, breasts, and thighs, and rarely to the cervical and inter- 
scapular regions. 

In submucous growths the pain may be due to intermittent 
uterine contractions excited by the growing fibroids. Such pains are 
usually colicky, and are most severe during the period of menstrual 
congestion. If, as sometimes happens, the outflow of menstrual 
blood is obstructed, there will be a so-called obstructive dysmenor- 
rhoea due to intrauterine tension and to an effort on the part of the 
uterus to expel the blood clots. Pain in most cases of uterine 
fibroids first manifests itself at the menstrual period, when the uterus 
and tumor are swollen and tender from congestion. 

The ''birth of a fibroid" — i. e., the expulsion of a submucous 
fibroid— is associated with labor-like pains of astonishing severity. 
After the flow is well started the pain may be relieved. The more 
abundant the blood supply to the tumor the greater will be the 
menstrual swelling. Acute pain on external pressure may be ex- 
perienced in the menstrual period from irritation of the perito- 
neum. Mechanical irritation of the peritoneum caused by the 
movable tumor may set up a localized peritonitis, and this in turn 
adds to the pain and discomfort. 

Pressure of a fibroid upon the abdominal and thoracic viscera 
gives rise to a variety of symptoms. Pressure upon the bladder 
causes vesical tenesmus, frequent urination, and catarrh of the 
bladder. A small subperitoneal fibroid attached to the anterior 
surface of the uterus may cause serious disturbance in the bladder. 
The uterus may be compressed, leading to hydronephrosis, pyo- 
nephrosis, and ursemia. The urethra is rarely pressed upon by 
the tumor, though the bladder may be elevated and the urethra 
stretched and distorted. 



328 SPECIAL DIAGNOSIS 

Pressure upon the rectum may cause constipation, rectal tenes- 
mus, a sense of fulness and pressure in the rectum, and a catarrhal 
discharge. 

Pressure upon the veins of the pelvis may cause oedema and 
varicosities of the lower extremities. 

When the tumor is large enough to fill the abdominal cavity, 
pressure upon the bowel and stomach will interfere with digestion, 
and pressure upon the diaphragm will hinder its excursions, and 
thereby interfere with the functions of the heart and lungs. Great 
intra-abdominal pressure caused by large fibroids undoubtedly 
embarrasses the functions of the kidneys. 

Torsion of the pedicle of a fibroid is possible; furthermore, it is 
possible for a fibroid to cause torsion of the uterus. (See Fig. 72.) 
In this manner a fibroid may be completely twisted from the uterus. 
Such an event must necessarily be followed by gangrene of the 
tumor, unless an adequate blood supply is conveyed by the adhe- 
sions. Immediately upon the twisting of the pedicle there is severe 
abdominal pain, together with a sudden increase in the size of the 
fibroid. Vomiting and collapse follow — the clinical picture being 
not unlike that of a strangulated hernia, or the twisted pedicle of 
an ovarian cyst. When the torsion is partial or slow in its develop- 
ment, the symptoms will be less pronounced. When a fibroid 
becomes infectious or gangrenous, the event will be ushered in by 
a rise in temperature, chills, and pain. The tumor will be tender 
to pressure and increased in size. When submucous, a stinking 
discharge will come from the uterus. When a subperitoneal fibroid 
becomes gangrenous, the symptoms are less characteristic. Pain 
may be absent. Rise of temperature and tenderness on pressure 
are all but constant symptoms. The usual signs of peritonitis 
supervene when the affection spreads to the peritoneum. 

Calcareous degeneration gives rise to no symptoms suggestive of 
the condition. There is but one sign upon which a positive diag- 
nosis can be based, and that is the expulsion of part or all of the 
growth in which the calcareous deposits are found. This seldom 
occurs, because submucous fibroids rarely calcify and are seldom 
expelled. 

Objective Signs. It is evident that a positive diagnosis cannot 
be made from the above subjective signs. From them we can only 
conclude that there is a swelling of some sort causing the pressure 



DIAGNOSIS OF FIBBOMYOMA OF THE UTEBUS 329 

symptoms. A physical examination is indispensable in making a 
diagnosis. 

The diagnosis is based upon the recognition of a tumor connected 
with the uterus and having certain fairly definite characteristics. The 
recognition of a fibroid of the uterus is ordinarily easy, but may be 
rendered difficult by various circumstances. In order that a diag- 
nosis of fibroids be made the tumor must either be seen or outlined 
by the examining hands. Many conditions may exist to render 
such a procedure impossible, and at such times the diagnosis must 
be reserved until an exploratory incision has been made. 

Small interstitial fibroids can only be suspected from the size and 
irregular consistency of the uterus. In large, interstitial fibroids 
there is difficulty in outlining the uterus apart from the tumor. 
The sound passed into the uterine cavity will locate the uterus, and 
when combined with a conjoined examination it should be possible 
to determine the existence of a fibroid and its position relative to 
the uterus. In outlining the respective positions of the uterus and 
tumor it is important to recognize their difference in form and con- 
sistency. 

A subperitoneal fibroid is ordinarily identified by a conjoined 
examination. When the tumor is large abdominal palpation may 
alone be sufficient. The form, consistency, and relation to the 
uterus may suffice for a diagnosis. Much dependency may be 
placed upon the firmer consistency of the tumor as compared with 
the uterus, and particularly is this of importance in differentiating 
a fibroid from a pregnant uterus. 

As with interstitial fibroids, great difficulty may be experienced 
in outlining a large sessile subperitoneal fibroid from the uterus. 
The irregular outline, the firmer consistency, the groove or angle 
which may mark the connection between tumor and uterus are 
points which, together with the use of the sound, should suffice for 
a diagnosis in the majority of cases. Greater difficulty is experi- 
enced with multiple subperitoneal fibroids. 

In large fibroids a vascular souffle is often heard and may be 
mistaken for the souffle of pregnancy. The pulsations of the aorta 
may be transmitted through the tumor and be mistaken for the 
fetal heart beat. 

Intraligamentary or broad ligament fibroids are recognized by 
their point of attachment along the side of the uterus, by their 



330 SPECIAL DIAGNOSIS 

lessened mobility, by the course of the adnexse which run over the 
tumor, and by the crowding of the uterus to the opposite side of the 
pelvis. The growth may spring from the supravaginal portion of 
the cervix or from the side of the uterine body. 

Plate VII. represents a single large subperitoneal fibroid causing 
a rounded protuberance of the abdomen. Plate VIII. represents 
an abdomen distended by multiple subperitoneal fibroids, in which 
the irregularities are plainly visible. 

Submucous fibroids can only be diagnosed with certainty when 
they are seen protruding through the cervix or when palpated 
through the cervical canal. The hemorrhage and uterine colic will 
suggest the possible presence of a submucous fibroid, but the diag- 
nosis must be kept in reserve for a physical examination. Within 
the uterine cavity the finger detects a firm, rounded tumor con- 
nected with the uterus by a broad base or pedicle. The fibroid may 
be felt as a circumscribed bulging tumor upon the mucosa. With 
the sound or curette similar observations may be made, though 
with less certainty. 

Fibroids of the cervix are not difficult to diagnose when attached 
to the vaginal portion. Their attachment to the cervix can be 
demonstrated by inspection or by the finger and sound. Small 
interstitial fibroids of the cervix are recognized by the firm, rounded, 
and sharply circumscribed area of resistance which characterizes 
their presence. 

The use of the sound in the diagnosis of uterine fibroids is not to 
be underestimated, yet its application should be restricted to the 
cases in which a conjoined examination fails to clear up the diag- 
nosis. Aside from the danger of infection, there is the added risk 
of perforating the uterus at a point possibly thinned by the tumor. 

Great difficulty may be experienced in the passage of the sound. 
The tumor may be impinged upon and give the impression that 
the depth of the uterus is short in contrast to the usual lengthening 
of the uterine cavity as found in the presence of submucous and 
interstitial fibroids. The shape of the uterine cavity is also to be 
noted by the sound. It may be encroached upon and greatly dis- 
torted, so much so that the sound cannot be passed to the fundus. 

Palpation of the Adnexa and Round Ligaments. In favorable 
cases the tubes and round ligaments can be palpated in a conjoined 
examination. It is observed that their location and point of attach- 



DIAGNOSIS OF FIBBOMYOMA OF THE VTEBVS 33I 

ment are altered by the tumor, and it is sometimes possible to 
locate the tumor in its relation to the uterus by observing the 
position of the adnexa and round ligaments. 



Fig. 141. 




M 

It is sometimes possible to locate a fibroid in relation to the uterus by palpating the uterine 

appendages and round ligaments. 
I. The fibroid is subperitoneal and sits upon the fundus, hence the appendages and round 
ligaments are not disturbed in their relative positions. II. The fibroid is subperitoneal and 
sits upon the posterior wall of the uterus, and extends backward and to the left. The 
appendages and round ligaments are not disturbed in their relative positions. III. The 
fibroid is interstitial and evenly distends the uterus, hence the appendages and round liga- 
ments are separated on the same plane. IV. The fibroid is interstitial and lies in the fundus 
and right cornua. The right tube and round ligament are elevated and dislocated outward. 

Where the uterus is small and a larger fibroid sits upon the fundus 
the tumor may be mistaken for the uterus. The attachment of 



332 SPECIAL DIAGNOSIS 

the tubes and round ligaments when determined will indicate the 
position of the uterus apart from the tumor. The sound will con- 
firm the findings. 

A submucous or interstitial growth evenly distending the uterus 
will separate the attachments of the round ligaments and adnexse. 
An interstitial fibroid of the anterior wall will separate the round 
ligaments and tubes, and if to one side of the median line the cor- 
responding tube and round ligament will be elevated above the 
other. An interstitial fibroid on the posterior surface of the uterus 
will tend to approximate the appendages. 

If the fibroid is on the side of the uterus the corresponding round 
ligament and tube may be elevated. Fig. 141 illustrates these facts. 

The diagnosis of malignant degeneration of a fibroid is discussed 
in the chapter on Sarcoma of the Uterus. 

DIFFERENTIAL DIAGNOSIS OF FIBROIDS OF THE UTERUS. 

Fibroids of the uterus commonly appear during the period of 
sexual maturity when pregnancy, inflammatory lesions, and dis- 
placements are likely to arise, and it is for this reason that the 
differential diagnosis is of such importance. 

Interstitial Fibroids. Chronic Metritis. 

1. Irregular enlargement of the uterus 1. Uniform enlargement. 

unless tumors are small. 

2. Variable consistency. 2. Uniform, firm consistency. 

3. Not tender to pressure. 3. Commonly tender to pressure. 

4. Uterus freely movable. 4. Uterus usually restricted in its movements. 

5. No history of infection, 5. History of infection. 

6. Symptoms of uterine catarrh not 6 Symptoms of uterine catarrh generally 

common. present. 

When the fibroids are multiple and small it may be impossible 
to distinguish such a lesion from chronic metritis. The clinical 
history cannot be relied upon. 

Uterine Fibroids. Uterine Pregnancy. 

1. Usual signs of pregnancy absent. 1. Present. 

2. Tumor of firm consistency, rarely soft. 2. Soft and elastic. 

3. Intermittent uterine contractions absent. 3. Present. 

4. Irregular and asymmetrical growth. 4. Rate of growth regular and symmetrical. 

5. Slow growth. 5. More rapid growth. 

6. Cervix firm, not patulous. 6. Cervix soft and patulous. 

7. Positive signs of pregnancy absent. 7. One or more present, i. e. : 

a. Fetal heart tones. 
6. Fetal bruit. 

c. Active fetal movements. 

d. Palpation of fetal parts. 

e. Ballottement. 



DIAGNOSIS OF FIBROMYOMA OF THE UTERUS 



333 



Of greatest importance in the differential diagnosis of fibroids 
from early pregnancy is the uniform rapid growth of the pregnant 
uterus, the intermittent uterine contractions and characteristic 
doughy consistency. Later, when positive signs of pregnancy are 
elicited, there should be no mistaking the fact of pregnancy. 



Fig. 142 




Subperitoneal fibroid of the uterus in the third month of pregnancy. On the posterior 
surface of the body of the uterus and cervix is a liard subperitoneal fibroid the size of a 
fetal head. The uterine wall is abnormally thickened. The ovary is cystic and adherent 
to the tube and uterus. (Specimen was removed by Dr. J. Clarence Webster.) 



A large, soft, interstitial fibroid may evenly distend the uterus. 
Its soft consistency, regular outline, and rapid growth may suggest 
the presence of a pregnant uterus. In addition to the above find- 
ings, there may be nausea and vomiting, enlargement of the breasts. 



334 



SPECIAL DIAGNOSIS 



softening and discoloration of the vaginal portion of the cervix. 
With such a condition it may be impossible to make a diagnosis 
from early pregnancy. Keeping the case under observation for a 
few weeks, it will be noted that the growth is slower than in preg- 
nancy, that there are no intermittent contractions, and that none of 
the positive signs of pregnancy develops. 



Fig, 143 




Multiple interstitial fibroids in a full-term pregnant uterus. The placenta is retained in 
situ. The irregular contractions of the uterus due to the presence of the fibroid tumors are 
shown by the irregular course of the uterine cavity. (The uterus was removed by Dr. J. 
Clarence Webster immediately following a Csesarean section.) 



But the diagnosis of fibroids complicated by pregnancy is often 
a difficult problem. Small subperitoneal fibroids may be mistaken 
for part of the foetus. Under the influence of pregnancy a fibroid 
grows rapidly and becomes soft. It is, however, unusual for the 



DIAGNOSIS OF FIBBOMYOMA OF THE UTEBUS 335 

growth to become as soft as the pregnant uterus, so by the circum- 
scribed area of firmer resistance the fibroid is outHned apart from 
the pregnant uterus. If the examination is made during a uterine 
contraction this difference in consistency between the uterus and 
fibroid is not evident. Repeated and prolonged examinations may 
be required. 

No tumor other than a pregnant uterus displays these intermittent 
contractions. 

When through a morbid state of the contained foetus the uterus 
remains in a condition of tonic contraction, the discovery of an 
interstitial fibroid may be impossible. When in doubt as to the 
diagnosis, and the condition of the patient does not demand imme- 
diate interference, it is always advisable to await developments and 
make examinations at frequent intervals. 

Subserous Uterine Fibroids, Hematoma anb Hematocele. 

1. No history of recent pregnancy. 1. Frequently history of previous pregnancy. 

2. Slo"w, continued development. 2. Sudden development. 

3. Consistency firm, rarely soft. 3. Consistency at first is fluctuating, later is 

doughy. 

4. Sharply circumscribed tumor, 4. Ill-defined tumor. 

5. Exploratory puncture negative. 5, Exploratory puncture — blood obtained. 

Gangrene with a fatal termination has been known to follow an 
exploratory puncture of a fibroid. It is not always possible to 
remove blood through an exploratory needle because of the firm 
clotting. In this event an exploratory incision must be sub- 
stituted. 

For the differential diagnosis of uterine fibroids from displace- 
ments of the uterus, carcinoma, sarcoma, tubal and ovarian swell- 
ings, and pelvic exudates see respective chapters on these subjects. 

A case in the experience of the author, and another recently 
observed by Bayard Holmes, presented a soft subperitoneal fibroid 
near the horn of a pregnant uterus which was thought to be an 
ectopic gestation. In both cases the pregnancy was early; the 
fibroids were not discovered until the pregnant uterus began to 
rise out of the pelvis, bringing the softened tumor with it. 

Fibroids Imperil Life. Fibroids may exist without the knowl- 
edge of the individual carrying them. Again, they may be the 
source of much distress and may be the direct or indirect cause of 
death. The following are the events which seriously infiuence a 
myomatous patient* 



336 SPECIAL DIAGNOSIS 

1. Hemorrhage is the most common though not the most serious 
event. Little need be added to what has already been said. While 
the patient's health may be seriously influenced by loss of blood 
it must be remembered that this is not alone the result of a loss of 
large quantities of blood. What may appear to be an insignificant 
amount when continued over many months and years may pro- 
duce a chronic anaemia not unlike pernicious anaemia in its clinical 
features. Excessive bleeding from a fibroid during and between 
menstrual periods usually indicates septic infection of the tumor. 

2. Complicating Pregnancy. The gravity of fibroids complicating 
pregnancy depends in great part upon the size and position of 
the tumor. Submucous fibroids have the most serious influence 
and subperitoneal the least. 

A submucous fibroid predisposes to abortion, interferes with the 
complete emptying of the uterus and hence renders the patient 
liable to infection and hemorrhage. Septic infection and sloughing 
of these growths may follow. Subperitoneal fibroids may become 
cedematous or infected and lead to peritonitis. Twisting of the 
pedicle of a subperitoneal fibroid is an occasional accident which 
leads to severe pain, gangrene of the tumor, and peritonitis. In the 
Baudelocque, 1895-1900, were 85 cases of uterine fibroids com- 
plicated by pregnancy. Meheut reports 67 of these having gone 
to full term, 13 aborted, in two instances abortion was induced, and 
death occurred in two cases. 

Tait found in literature 39 cases of a polypoid myomata 
complicating pregnancy. Of this number gangrene of the tumor 
occurred in 6, spontaneous expulsion of the foetus together with 
much loss of blood in 3, myomectomy in 7, normal delivery in 10, 
maternal deaths in 8 (19.5 per cent.). 

3. Septic infection is a most serious complication and demands 
immediate and radical treatment. 

The infection may be conveyed to the fibroid by instruments 
and fingers. More often it arises through an infected puerperal 
wound of the uterus. Tumors adhering to bowel may be infected 
from the bowel. A submucous fibroid protruding through the 
cervix into the vagina may be so constructed as to partly shut off 
the blood supply and lead to oedema and congestion which later 
may result in gangrene of the fibroid with all its remote conse- 
quences, 



DIAGNOSIS OF FIBROMYOMA OF THE UTERUS 337 

4. Torsion of the Pedicle. A long, slender pedicle of a subperi- 
toneal fibroid may permit of rotation of the fibroid in exactly the 
same manner as in ovarian cysts. The accident is a rare one. 
Conditions which favor rotation of the fibroid are: a long slender 
pedicle, free fluid in the abdomen, sudden increase in the intra- 
abdominal pressure, pregnancy, the sudden emptying of the preg- 
nant uterus, and lastly, direct injury. The consequences of such 
twisting are gangrene of the fibroid followed by peritonitis unless 
surgical interference is timely. Calcareous fibroids have twisted off 
and have been found free in the abdominal cavity, giving rise to no 
disturbances. 

5. Impaction in the small pelvis may occur from all varieties 
of fibroids, but it is far more common in subperitoneal fibroids. 
This event is especially liable in pregnancy, at which time the tumor 
and uterus are growing rapidly. Retention of urine may be caused 
by direct pressure upon the urethra. Frequent urination results 
from pressure upon the bladder. When long continued the bladder 
and kidneys may suffer permanent injury. Bland Sutton lays down 
the rule that "when a woman between thirty- five and forty- five seeks 
relief because she suffers from retention of urine for a few days pre- 
ceding each menstrual fiow it is almost certain that she has a fibroid 
in the uterus." Broad ligament fibroids are especially liable to 
impaction, and the pressure exerted by them upon the ureter, 
pelvic nerves, and bloodvessels may early become serious. 

6. Intestinal obstruction may arise from direct pressure of the 
growth or from the entanglement of the intestinal loops with the 
pedicle of a subperitoneal fibroid. 

7. Nutritive changes in the fibroid may imperil life. Fibroids 
grow almost invariably during the period of gestation, and particu- 
larly in the early months. The increase in the size of the tumor 
may be so rapid and to such an extent as to seriously embarrass 
not only the course of pregnancy and labor, but also the functions 
of the abdominal viscera. 

During labor degenerative changes may occur in the fibroid as 
the direct result of trauma. Such tumors are usually located low 
in the pelvis. According to Hammarschlag, these changes are not 
necessarily dependent upon trauma, but may arise independently 
of injury. It must be admitted that fibroid tumors of the uterus, 
even of large proportions, seldom impede the progress of labor. 

22 



338 SPECIAL DIAGNOSIS 

Statistics from the large clinics of the world justify this asser- 
tion. 

During the lying-in period the usual tendency of fibroids is to 
undergo involution even to the point of apparently disappearing. 
Hammarschlag finds that the sudden cessation of the very free 
blood supply which exists during pregnancy sometimes brings 
about marked necrotic changes in the tumor which may seriously 
affect the patient. 

(Edema of the tumor may occur during pregnancy, labor, and 
the lying-in period. During pregnancy such an event must be 
looked upon as a fortunate happening, inasmuch as the softening 
of the tumor permits of such moulding of the growth by the 
pressure of the advancing child that delivery will be favored. 

Hemorrhage from the severing of adhesions may arise during 
the latter part of pregnancy and in labor. Fatal results are recorded. 
This event is especially liable when artificial reposition is attempted. 
Hemorrhage and peritonitis have been known to result from the 
twisting of the pedicle of a subperitoneal fibroid. Expulsion of 
a submucous fibroid during labor and the puerperium is a not 
infrequent event and may be followed by serious infection. 

8. Cardiopathy of uterine fibroids is a condition demanding serious 
consideration because of the gravity of the condition and its fre- 
quent occurrence. Various functional and organic lesions of the 
heart are found to be associated with uterine fibroids in about 40 
per cent, of cases, not simply as a coincidence but as an inevitable 
result in many cases. It is therefore imperative to look to the 
heart in all cases. 

The explanation is not always forthcoming. The following are 
presented by Wilson: 

a. Excessive size of the tumor, embarrassing the excursions of 
the ribs and diaphragm. 

h. Pressure upon the ureters, primarily affecting the kidneys. 

c. Menorrhagia causing anaemia, which in turn causes nutritive 
changes in the heart. 

d. Disturbances of the functions of the cardiovascular system 
from the influence of the tumor upon the sympathetic and cerebro- 
spinal systems. 

, e. Rapid failure in compensation where fibroids complicate a 
pre-existing lesion of the heart. 



DIAGNOSIS OF FIBROMYOMA OF THE UTERUS 339 

9. Malignant degeneration of uterine fibroids occurs in 3 to 4 per 
cent, of all cases, according to Winter. These changes are almost 
invariably .sarcomatous. 

Coincident malignant disease of the uterus with fibroids has 
been frequently observed, but to establish a relation of cause and 
effect is not justifiable. The fact that they are coincident should 
lead us to consider the possible existence of the two lesions in all 
cases. 



CHAPTER XXyill. 

THE DIAGNOSIS OF CARCINOMA OF THE UTERUS. 

Topographical Classification . 

1. Vaginal portion. 

2. Cervix. 

3. Body of uterus. 
Etiology. 

Anatomical Diagnosis. 
Clinical Diagnosis. 
Microscopic Diagnosis. 
Differential Diagnosis. 
Diagnosis of Extension. 
Endothelioma. 

TOPOGRAPHICAL CLASSIFICATION OF CARCINOMA OF THE 

UTERUS. 

Carcinoma may arise from any portion of the uterine mucosa 
both within the uterus and covering the vaginal portion of the cer- 
vix. The classification proposed by Ruge and Veit is as follows: 

1. Carcinoma of the vaginal portion of the cervix, including 
the vaginal surface of the cervix from the external os to the vault 
of the vagina. 

2. Carcinoma of the cervix, including the mucosa of the cer- 
vical canal. 

3. Carcinoma of the body of the uterus, including the mucosa 
from the internal os to the horns of the uterus. 

It will be observed that the location of the new-growth is not 
only of pathological interest, but has much to do with the manner 
of diagnosis, the clinical manifestations, prognosis, and treatment. 

ETIOLOGY OF CARCINOMA OF THE UTERUS. 

The essential cause of carcinoma is as yet unknown. Certain 
predisposing causes are well recognized and demand consideration. 

(340) 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 341 

Age. We find carcinoma of the uterus commonly appearing about 
the time of the menopause. Carcinoma of the vaginal portion more 
often makes its appearance immediately preceding the menopause, 
and carcinoma of the body usually appears a few months or years 
later. The earliest recorded case appeared at eight years of age. 
I have lately observed a case of carcinoma of the vaginal portion 
in a woman, aged ninety-three years, forty-eight years after the 
menopause. 

In 3385 cases of cancer of the uterus Gusserow found but 2 
originating before twenty years of age. 

Heredity, while playing an important role, is of less importance 
as an etiological factor than was formerly believed. In 142 cases 
of uterine carcinoma Roger Williams found that heredity plays 
some part in their development in 19.7 per cent. 

Race. It has been said that the negress is particularly exempt 
from carcinoma of the uterus. Later observations tend to disprove 
this view, indicating that the negress is little less susceptible than the 
white woman. Uterine carcinoma is believed to be more common 
in Europe than elsewhere, and is said to be rare in the tropics. 

Childb earing appears to have an important relation to the devel- 
opment of carcinoma of the vaginal portion. The author has seen 
but two carcinomata of the vaginal portion in nulliparae whose 
cervices have never been dilated. The great rarity of carcinoma 
of the cervix in nulliparse speaks for the influence of trauma as a 
factor in the development of cancer. Carcinoma of the body of 
the uterus is said to be more frequent in nulliparae. 

There can be no question that the inflammatory lesions of the 
uterus (endometritis and erosions) are not seldom the starting 
points of carcinoma; but that scars in the cervix are such is justly 
questionable. While fibroids and carcinoma are often associated 
in the uterus, it is not probable that the one is in any way depen- 
dent upon the other for its existence. So frequently, however, is 
carcinoma found to develop in a myomatous uterus, that we are 
justified in regarding with suspicion of carcinoma a myomatous 
uterus that begins to bleed after the menopause. 

Carcinoma of the uterus is found more frequently in the lower 
orders of society. These classes are more susceptible to and 
neglectful of infections and traumatisms. On the other hand, 
the lesion is less frequently seen among the uncivilized classes. 



342 SPECIAL DIAGNOSIS 

Cohnheim's theory of cell inclusion is not supported by observa- 
tions made upon the carcinomatous uterus. 

Leopold concludes from a series of experiments that pure cultures 
of the blastomycetes may be found in fresh carcinoma of the ovary. 
He injected a pure culture into the testicle of a rat. The animal 
died, and on the peritoneum were found nodules in which were 
similar blastomycetic organisms. Leopold infers that this organism 
may be the cause of carcinoma in man. 

The frequency oj carcinoma of the uterus is variously stated. 
Welsh found that in 31,482 cases of carcinoma 29.5 per cent, were of 
the uterus. In point of frequency the uterus takes second rank to 
the stomach as a primary seat of carcinoma. There can be no 
doubt but carcinoma is on the increase, though it is only fair to 
admit that the perfected means of diagnosis account in large part 
for the statistics. 

Roger Williams estimated that over 10,000 women suffered from 
uterine carcinoma in England and Wales in 1898. He further 
estimated that of the deaths occurring in women over thirty- 
five years of age one in thirty-five is due to carcinoma of the 
uterus. 

ANATOMICAL DIAGNOSIS OF CARCINOMA OF THE UTERUS. 

1. Carcinoma of the vaginal portion of the cervix may tend to 
grow superficially into the vagina, forming a polypoid or cauliflower 
growth, or it may deeply infiltrate the cervix. 

L Cauliflower carcinoma of the vaginal portion of the cervix is 
seen as a sessile or pedunculated growth arising from one or both 
lips of the cervix. It varies in size up to the complete filling of the 
vagina. The surface is generally covered with a slimy, gangrenous 
deposit. The whole mass bleeds readily to the touch and is friable. 
The surface is uneven, nodular, polypoid, or villous. 

2. Infiltrating carcinoma of the vaginal portion of the cervix appears 
in the early stage as an irregular thickening and hardening of the 
cervix. The anterior lip is most often first involved. 

Cullen distinguishes three stages according to the degree of infil- 
tration and disintegration of the cervix. W^hile this classification 
is purely arbitrary, it will be found convenient for purposes of 
description. 



PI .ATP XI I\' 




Cant 



Vaginal Portion of the Cervj liir-d stage- 



The entire C3ervix is disintegrated. 



vault of til 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 343 

Stage 1. This is the Stage of Infiltration in the absence of disin- 
tegration. The surface is hard, friable, and uneven. The color 
of the surface is glistening, bluish-white. Cross-sections of the 
growth show a gray or yellowish-gray surface, often cutting like 
cartilage. Fibrous striations are seen to course through the struc- 
ture, isolating nests of friable homogeneous tissue, the so-called 
cancer nests. By squeezing the surface, these nests may be emptied 
of their cell contents, leaving small, shallow depressions. Such 
nests are not to be confused with Nabothian follicles filled with 
inspissated mucus. The two may be found in the same section. 
Unfortunately, cancer of the vaginal portion is seldom observed at 
this stage, because of the mild symptoms which prevail. Not infre- 
quently there is an entire absence of symptoms. While impossible 
to say without an anatomical dissection, it is probable that the 
growth is still confined to the cervix. Yet it must be borne in mind 
that not only regional but general dissemination of the carcinoma 
may occur at this stage. 

Stage 2. This is the Stage of Moderate Disintegration. The 
carcinomatous tissue has partly disintegrated, leaving a depression 
with irregular, hard, elevated margins. The base of the ulcer is 
uneven, and covered with a stinking slough of a grayish-yellow or 
gangrenous character. Upon handling the affected tissue bleeds 
freely and is friable. In this stage the growth is rarely confined 
to the cervix. More than half the vaginal tissue may be lost. Ulcera- 
tion of a cancerous growth does not usually begin until the disease 
has run about half its course. In a small proportion of cases the 
growth never ulcerates. (See Plate XLIV.) 

Stage 3. This is the Stage of Complete Disintegration of the 
Vaginal Portion of the Cervix. In the vault of the vagina is a 
sloughing, stinking, ragged crater. No cervix is to be seen or felt. 
The vaginal walls are invaded and form the margins of the crater. 
The paravaginal connective tissue, broad ligaments, and utero- 
sacral ligaments are infiltrated. The growth is slow to pass beyond 
the internal os into the cavity of the uterus, but may extend. to the 
fundus. Isolated cancerous nodules may lie in distant portions of 
the vaginal wall. Contact growths may develop upon opposing 
surfaces. The bladder is involved late, and the rectum still later, 
as a rule. Only in the very late stage is the peritoneum invaded. 
The iliac glands are the first of the lymphatics to be invaded, but 



344 



SPECIAL DIAGNOSIS 



these are late in being affected, and may entirely escape. Metastatic 
growths in distant parts of the body are seldom observed. 

II. Carcinoma of the Cervix. Carcinoma of the cervix takes 
its origin from the epithelium of the cervical mucosa confined 
v^ithin the boundaries of the external os below and the internal os 



Fig. 144 




Lymphatics of uterus and upper third of vagina, and iliac and lumbar glands. (Russell.) 

above. The usual site of development is immediately above the 
external os on the anterior lip. 

The carcinomatous growth may involve all or a part of the 
mucosa. It may assume a nodular or cauliflower appearance, 
or may infiltrate the underlying tissue. The entire cervix may 
be infiltrated and will eventually disintegrate, leaving a crater-like 



PLATE XLV. 




Carcinoraa of the Cervix, with. Partial Disintegration. 



The growth! is soft, friable, and. bleeding. The vagina and body of the uterus 

are invaded. 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 345 

structure with a thin shell. The lips of the cervix may close in over 
the growth, hiding it from view. It is seldom, if ever, that the lips 
are disintegrated, but in the late stages they are infiltrated and 
glazed. On cross-section the carcinomatous mass is cartilaginous, 
yellowish-white, and glistening. The advancing border is irregular 
and blends into the normal tissue. The body of the uterus and 
vagina may be invaded either by direct extension or by metastasis. 
The cervical canal may be occluded by the new-growth and be 
followed by fluid distention of the uterus (pyometra and hsemato- 
metra) and tubes (hydrosalpinx, hsematosalpinx, and pyosalpinx). 

Extension of Carcinoma to Surrounding Structures. The para- 
vaginal connective tissue is invaded comparatively early. It is 
unusual to observe a case before the broad ligaments are involved, 
hence the prognosis is grave. 

The peritoneal cavity is invaded late. The tubes, ovaries, bladder, 
and rectum are seldom attacked. The iliacs are the first of the 
lymphatic glands to be invaded. Metastasis to distant organs is 
said to seldom occur. Roger Williams, however, found 20 per cent, 
of his cases had disseminated cancerous foci in distant parts of the 
body. Adenopathy has been known to supervene two years before 
death, though, as a rule, death follows much more closely upon 
the involvement of the glands. Winter found the iliac glands 
involved in 22 per cent, of cases of cancer of the cervix. He found 
four cases of advanced cancer of the cervix without involvement 
of these glands. Emil Hies has made extended observations on 
the involvement of the lymphatic glands in cancer of the cervix. 
He has shown that the glands of the pelvis are often cancerous 
when no larger than normal. Again, they are sometimes enlarged 
from a hyperplasia, the result of an ulcerative process in the growth. 
Extensive glandular involvement contraindicates all but palliative 
treatment. 

The percentage of glandular involvement ' in uterine carcinoma 
is difficult to determine. Peisser estimates that 50 per cent, of 
uterine cancers are accompanied by glandular involvement, and 
Williams estimates 72 per cent. These investigations were not 
verified by the microscope, hence cannot be reliable, for Ries has 
conclusively shown that there may be no enlargement of the glands 
in advanced cancerous invasion of the gland structure. Ries 
further states that the size of the cancer in the cervix is in no 



346 SPECIAL DIAGNOSIS 

regular proportion to the size of the affected gland. He reports a 
case of his own in which the primary cancer in the vaginal portion 
was not larger than a thumb-nail, but the largest cancerous gland 
was the size of a pigeon's egg. 

It is of clinical interest to inquire whether the parametrium 
is always involved prior to the pelvic lymph glands. If so, then 
failure to detect infiltration of the parametrium would lead us to 
infer that the pelvic glands are not involved, and hence the Ries- 
Wertheim operation for dealing with the pelvic glands would not 
be indicated. Puppel, Cullen, Pryor, Kelly, and others are of this 
opinion, but Wertheim and Ries warn us of the uncertainty of such 
conclusions. The only positive means of demonstrating the presence 
or absence of cancer cells in the pelvic lymph glands is afforded by 
serial microscopic sections. Williams points out that in advanced 
cases of cervical cancer the supraclavicular glands are occasionally 
enlarged (Trousier's sign). For a more extended discussion of the 
subject of the lymph glands in uterine cancer see Gellhorn's article 
in American Gynecology, November, 1902. 

III. Carcinoma of the Body of the Uterus. Carcinoma may 
arise from any part of the mucosa of the uterine body, either as a 
circumscribed or as a diffuse growth. The surface is never smooth. 
It begins as a shaggy growth studded with delicate villosities, 
which may later enlarge and coalesce into polyps or form twig-like 
processes with numerous offshoots. In late and far-advanced cases 
the growth presents the appearance of brain tissue. The entire 
uterine cavity may be filled with the cancerous growth. The mus- 
culature of the uterus is very slowly invaded, and it is for this 
reason that cancer of the body of the uterus is regarded as 
relatively benign. 

On cross-section the invading carcinomatous tissue, with its pale, 
homogeneous and glistening appearance, is in contrast to the mus- 
culature. The advancing border is irregular. When the serous 
covering of the uterus is invaded small grayish-yellow nodules are 
seen beneath the serosa. The growth is usually late in sloughing. 

Extension from the body of the uterus is extremely slow. The 
internal os is rarely trespassed; the broad ligaments are not infil- 
trated until late. The peritoneum may be directly invaded, but 
this is late, if at all. The bladder, rectum, tubes, and ovaries com- 
monly escape invasion. Metastasis to distant parts of the body is 



PLATE XLVI. 




Carcinoma of the Body of the Uterus. 

The cavity of the uterus is filled, with a brain-like mass— soft, friable, and 
bleeding. The growth does not extend into the cervix or deep into the 
musculature. 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 347 

late, and may never occur. Kroemer believes we find metastasis 
more common in carcinoma of the uterine body than of any other 
part of the uterus. 

As to the frequency of carcinoma of the body of the uterus, 
Schatz says that it occurs in 2.5 per cent., while Schauta says in 
13,8 per cent., of all carcinomata of the uterus. 

CLINICAL DIAGNOSIS OF CARCINOMA OF THE UTERUS. 

A work of this character could do no greater service than to em- 
phasize the importance of an early diagnosis in carcinoma of the 
uterus and to point out the methods of making such a diagnosis. 

No departure from the normal menstrual flow should he regarded 
as trivial in advanced years of life. We are not to he content with 
the supposition that it is a phenomenon of the change of life — too 
many lives have heen sacrificed hy such inferences. 

It is the family physician, not the specialist, who first sees these 
cases, and it is to him we must look for the early recognition of the 
danger, if not for a positive diagnosis. The practitioner must be 
firm in his demand for a local examination. Ignorance, sloth, 
prejudice, and false modesty are to be discountenanced. Where the 
physician, after a searching examination into the cause of the hem- 
orrhage, fails to satisfy himself, he should appeal to the specialist, 
whose services at this time are of greater value than in the treat- 
ment of the case, for the reason that it takes greater skill to make 
a diagnosis in these doubtful cases than it does to remove the uterus 
after the diagnosis is made. Since the early recognition of carcinoma 
of the uterus rests upon the microscopic examination of scrapings 
and excised pieces of the suspected portion, it is self-evident that 
only those especially trained in the w^ork are competent to make 
such a diagnosis. 

We may speak of acute and chronic cancers. 

Acute cancers, including those which run their course within 
a year, are frequently met with. Kiwisch observed a case which 
ran its entire course in five weeks, and Martin's case died within 
nine weeks of its inception. Associated with the growth in the 
uterus are febrile symptoms and general dissemination. 

Chronic cancers, including those which run their course in three 
years or more, are rare. Barker's case continued eleven years. 



348 SPECIAL DIAGNOSIS 

Carcinoma of the uterine body is slow in its course as compared 
with carcinoma of the cervix or vaginal portion. Odebrecht ob- 
tained a permanent recovery by operating on a cancer of the body 
five years and four months after it was known to exist. 

Symptoms in the early stage, while there is yet time to interfere, 
are at best only suggestive of the lesion. 

Hemorrhage is usually the first of the symptoms to appear. 
It is at first excited by some physical exertion, such as straining at 
stool, lifting burdens, and sexual intercourse. All departures from 
the normal menstrual flow, or all losses of blood not in relation to 
the menstrual period, call for a careful examination. The older the 
individual the greater the probability of carcinoma. In carcinoma 
the loss of blood is at first slight; more rarely does it begin with a 
profuse flow. A watery discharge may precede the flow of blood 
weeks and months, and is highly suggestive of carcinoma. The 
patient becomes anaemic, and strength fails as a result of the 
hemorrhage. In the late stage, when there is great enfeeblement, 
hemorrhage becomes less profuse, and may almost cease. 

Leucorrhoea is almost invariably present, at first in the form of 
a watery, odorless discharge, later as a thicker white or yellowish 
fluid, and, finally, as a stinking, dirty, bloody discharge. Such a 
discharge can only be regarded with suspicion; it is in no sense 
pathognomonic, and may be late in making its appearance. Slough- 
ing fibroids, decomposing placental tissue, and senile endometritis 
may cause a similar discharge. As in hemorrhage, so with such 
a leucorrhoea, a careful examination is imperative. 

Pain is seldom an early manifestation of carcinoma of the uterus, 
and is less reliable as a guide to diagnosis than is hemorrhage or leu- 
corrhoea. Not infrequently the growth is far advanced before pain 
is experienced. In such cases the pain begins when the growth has 
extended beyond the uterus. Pain and hemorrhage are often in 
inverse proportion. The pain is aggravated by the congestion, and 
when the flow of blood is considerable the congestion is relieved, 
and this in turn lessens the pain. Roger Williams found little or 
no pain in one-seventh of his cases. When present the pain of 
uterine cancers is generally referred to the groin, thighs, sacral or 
hypogastric regions. In the early stages the pain is of a dull aching 
and dragging character. Later, as the adjacent structures are 
involved, the pain may be severe and constant. 



PLATE XLVII, 




,^^ 



Cauliflower Carcinoma of the Cervix. 



An irregular papillary growth oeeupies both lips of the cervix. It is friable 
and. bleeding. There is no perceptible infiltration of the cervix. 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 349 

Miscellaneous sjrmptoms arise from extension to the surround- 
ing structures. The bowels become constipated, and defecation is 
painful from the pressure of the growth. As the rectum is invaded 
a mucous or mucohemorrhagic discharge comes from the rectum; 
finally, a rectovaginal fistula develops. Invasion of the bladder 
causes frequent urination, irritability of the bladder, bloody urine, 
and, finally, a vesicovaginal fistula. 

When the cellular tissue of the pelvis is involved there may be 
pain referred to the groin, thighs, and legs. (Edema of the legs, 
often of one side, may result from an involvement of the veins and 
lymphatics of the pelvis. In almost every case of advanced carci- 
noma of the uterus the kidneys are involved and ursemic symptoms 
may be manifest. 

Cachexia develops in the advanced stage, though it may be 
surprisingly late in making its appearance. The above symptoms 
are responsible for the cachexia. 

Uterine cancer patients seldom take to their bed until at least 
half of the course of the disease is run. Occasionally the general 
health fails from the beginning of the lesion, and on the other hand 
death has been known to result from the disease without marked 
general symptoms. A gradually increasing asthenia usually brings 
the case to a fatal termination. 

I. The diagnosis of carcinoma of the vaginal portion of the 
cervix can be made with greater ease and certainty than in any 
other portion of the uterus, because of the greater accessibility to 
touch and sight. 

In the infiltrating form with an overlying covering of mucous 
membrane the diagnosis is difficult without the aid of the micro- 
scope. 

The broadening of the cervix, the irregular nodular surface, the 
cartilaginous consistency, and the glistening, bluish color are not 
sufficiently characteristic. The friability and tendency to bleed 
when grasped by a tenaculum or when the finger-nail is gouged 
into it, are regarded by many of large clinical experience as 
characteristic of cancer, and altogether reliable in making a 
diagnosis. 

While much reliance can be placed on these signs, the microscopic 
examination of an excised piece of the suspected portion must be 
regarded as the conclusive test, without which a positive diagnosis 



350 



SPECIAL DIAGNOSIS 



is often impossible. When ulceration follows the diagnosis is made 
with greater ease. The hard, glistening, irregularly elevated 
border, together with the friability and tendency to bleed when 
handled, leaves little doubt as to the carcinomatous nature. There 
is then little need for the microscope to confirm the diagnosis. 

A cauliflower groAvth is more readily recognized as malignant 
than the infiUrating form, yet papillary erosion must be excluded, 



Fig. 145 




Primary carcinoma of the cervix, associated with a large submucous fibroid. 



and to make a careful differentiation the microscope will often be 
found indispensable. The greater the clinical experience of the 
examiner the larger will be the percentage of cases in which the 
diagnosis can be made from the clinical signs and symptoms. 
But there will remain a certain number in which the diagnosis can 
only be made by a microscopic examination of an excised piece of 
the suspected portion. (See Microscopic Diagnosis, page 353.) 



PLATE XLVIII. 




Carcinoma of Cervix, Advanced Stage. 



The eervix is almost completely disintegrated.. The vaginal 

surface is intact. 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 35I 

II. The diagnosis of carcinoma of the cervix is rarely made 
early, because the growth is not accessible to the sense of touch or 
sight, hidden as it is above the external os. Indeed, the growth 
may go on to an advanced stage, destroying the mucous membrane 
and underlying connective tissue, and yet be unsuspected. Where 
the destruction of tissue is seen through a vaginal speculum the 
diagnosis is not difficult, but this is not possible in the early stage 
when a radical cure is assured. 

When the cervix is artificially dilated bleeding is profuse and 
tearing can scarcely be avoided. The finger or curette gouges out 
friable masses. The friability and bleeding of the tissue are so 
characteristic as to leave little doubt of the carcinomatous nature of 
the growth. It is scarcely necessary to resort to the microscope 
to confirm the diagnosis. 

III. The diagnosis of carcinoma of the body of the uterus 
presents the greatest possible difficulties. There are no symptoms 
that may be regarded as pathognomonic; the lesion is beyond the 
reach of the examining finger, and cannot be brought under inspec- 
tion. The general nutrition of the individual bears little relation 
to the stage of the growth. She may retain her weight into the last 
stage. (See Plate XLVI.) 

Hemorrhage, a foul-smelling discharge, and pain occur in the 
order named, but it is possible for one or all of these symptoms 
to be absent, and more often there is nothing in the symptoms to 
suggest anything more serious than endometritis. 

// every menstrual irregularity occurring late in life and every 
intermenstrual or postmenopausal hemorrhage were regarded with 
suspicion of carcinoma, and a thorough search made into the cause, 
jew carcinomata oj the uterus would long go unrecognized. 

It is usual for the menstrual periods to have been regular, for the 
menopause to have passed in the ordinary way, and for some 
months or years to have intervened before the appearance of hemor- 
rhage. The author lately saw a case in which the menopause had 
been passed forty-eight years when hemorrhage returned. Even 
with this long interval the patient and friends thought the loss of 
blood was due to a return of the menses. Their suspicions were 
confirmed to their entire satisfaction when the flow of blood ceased 
in a few days and returned in four weeks. This disposition on the 
part of the patient to believe that postmenopausal hemorrhages are 



352 SPECIAL DIAGNOSIS 

the return of the menses is too frequently responsible for the high 
rate of mortality in carcinoma of the uterus. 

There is little difference in the subjective signs of carcinoma of the 
body of the uterus and those of the cervix or vaginal portion. The 
constitutional effects appear much slower. It is impossible to say 
when the growth begins. We commonly date the appearance of 
the carcinoma from the time of the onset of the watery discharge or 
hemorrhage, but it is to be borne in mind that these symptoms may 
be due to endometritis which has not as yet developed into a malig- 
nant growth; and, on the other hand, these symptoms may follow 
weeks and months after the beginning of malignant degeneration. 
The slow growth of carcinoma of the body of the uterus is illus- 
trated by a case of Cullen's, in which a hysterectomy was performed 
two years after the onset of symptoms, and the disease was seen 
to have made little progress. 

In a case operated upon by Dr. J. Clarence Webster the symptoms 
began three years previous to the operation. The growth was still 
apparently confined to the body of the uterus. 

We now spe that the subjective signs cannot be relied upon in 
making a diagnosis, and that we must depend largely upon physical 
signs. 

Bimanual palpation of the uterine body shows a slight uniform 
enlargement, together with some degree of softening. In the early 
stage the size and consistency of the uterus are not changed. In 
the advanced stage, when the growth has extended to the serosa, 
small nodules may be palpated on the outer surface of the uterus, 
giving the impression of small subperitoneal fibroids. 

Exploration of the uterine cavity is essential to a positive diag- 
nosis. This is accomplished by the examining finger, the sound, 
or the curette. 

After dilating the cervix sufficiently to admit the index finger, 
the entire surface of the endometrium can be explored. Soft, 
friable, and irregular elevations upon the surface are located, and 
may be scraped off by the finger for a microscopic examination. 
It is possible in the early stage for the growth that is not distinctly 
raised above the surface to escape the examining finger. 

The uterine sound will detect the irregularities upon the surface 
of the endometrium with less certainty, and will afford much less 
intelligent information regarding the consistency and extent of the 



PLATE XLIX. 




Infiltrating Carcinoma of the Cervix. 

The entire cervix is infiltrated, and. partially disintegrated. In the cavity 
of the uterus is a fungous growth (fungous endometritis). 



PLATE L. 



'■^A, 






Ai-.^iO W^-im 



^<w>' 






-f ^., 










'"H'?' 






'««rM*5, 









N 



.^. 









A^/AHagR.- 



Benign Papilloma of the Ovary. 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 



353 



growth. In carcinoma the sound will sink into the soft growth 
and cause considerable bleeding. 

An exploratory curettage followed by a microscopic examination 
of the scrapings will supply an absolute means of making a diag- 
nosis, and should be made in every case, no matter what the other 
findings may be. 

MICROSCOPIC DIAGNOSIS OF CARCINOMA OF THE UTERUS. 

We have learned that an early diagnosis of carcinoma of the 
uterus is seldom made from clinical manifestations or from the 
naked-eye appearances of the growth; that the only positive means 

Fig. 146 



*pv 



r 



.,<f»>-^ 



1 



of making an early diagnosis is by a microscopic examination of 
excised pieces and of scrapings removed by the curette. 



Fig. 147 






r 



I. Carcinoma of the Vaginal Portion of the Cervix. In ad- 
vanced cases where there is ulceration of the cervix and where the 
vagina and parametrium are infiltrated, a microscopic examination 

23 



354 SPECIAL DIAGNOSIS 

is seldom necessary. In the early stage no characteristic features 
may be observed by the naked eye, and it is in such cases that the 
microscope is indispensable. 

The technique of excising a piece of the cervix for a microscopic 
examination is to sterilize the vagina as for a vaginal operation; 

Fig. 148 









« 















Papillary carcinoma of the cervix. 

grasp the cervix with a tenaculum, and with knife or scissors remove 
a wedge including part of the suspected portion and part of the 
apparently healthy tissue. Following the incision catgut sutures 
are used to close the wound, and the vagina is packed with gauze. 
An anaesthetic is desirable, though not absolutely necessary. 



Fig. 149 






iy & 



:-.a;j;-S; ■■■■;:■ . ^ ^':A ^' IJ::\ 



)ll.«^ 



-'-*^ 



I' 



Squamous-cell carcinoma of the cervix. 

The microscopic appearance of an infiltrating squamous-cell carci- 
noma of the cervix is that of many layers of flat epithelium varying 
greatly in size and in form from the normal epithelium of the 
vaginal portion. The cells may be no larger than a leukocyte, or 
considerably larger than normal. The nuclei are relatively large, 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 



355 



often segmented. They take a deep stain and show many karyo- 
kinetic figures. A variable amount of protoplasm surrounds the 
nuclei. The cells, grouped in irregularly projecting columns, invade 



Fig. 150 
















Proliferation of the superficial columnar epithelium. The new-formed epithelium is seen 
to invade the connective tissue in the act of forming a malignant gland. 

the underlying tissues and may finally wholly replace the cervix. 
About the margins of these projecting columns is a round-cell infil- 
tration of the connective-tissue stroma. Cross-sections of these 

Fig. 151 




'^S'> asef -^ j» 






^ O •" «-' 'i-^S' —"'<: «sr-^ ■" ^ — 






»_ -«. t;;^ &**> 









Proliferation of the superficial columnar epithelium. The new-formed epithelium 
extends outward, forming papillary projections into which connective-tissue fibres project 
to form a framework. There is no invasion of the connective tissue. The figure represents 
the beginning of a malignant papillary growth. 



epithelial columns appear as "cancer nests" (Fig. 153), and in 
them "cancer pearls" (Fig. 152) are found. 

The microscopic diagnosis of a cauliflower carcinoma of the vaginal 
portion of the cervix is to be made from an excised piece of the 



356 



SPECIAL DIAGNOSIS 



suspected portion. The sections must be made perpendicular to 
the cervix, in order to observe the epithehal invasion of the latter. 
The finger-like projections which aggregate to make a cauliflower 
growth are composed of a framework of connective tissue which 



-.ti?', 



Fig. 152 






«»- 



Cancer pearl composed of concentric layers of hornified epithelium. 

contains a central bloodvessel, many round cells, and a variable 
number of invading epithelial cells (Fig. 154). The surface is 
covered with many layers of squamous epithelium not unlike 
those described above in the infiltrating form of carcinoma. The 



Fig. 153 




Cancer nest with a necrotic centre. 



epithelium invades the underlying connective tissue of the cervix, 
and it is this feature that gives the malignant character to the 
growth. Cancer nests may show various stages of degeneration. 
Giant cells are relatively abundant. Hyaline degeneration of the 
cancer cells is common, and the nuclei may be fragmented. 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 357 

Erosion carcinoma is a term implying malignant degeneration of 
an erosion of the cervix. The malignant changes commonly begin 
on the surface of the erosion, less frequently from the glands and 
follicles. In this way it is possible to have cylindrical-cell carcinoma 
in the vaginal portion of the cervix. 

Fig. 154 



'^-- ^^^^^^ 



m'h, 



^ 



:«.'?. 



A finger-like projection of a squamous-eell carcinoma of the cervix. 



II. Carcinoma of the Cervix. Two general histological forms 
of carcinoma of the cervix are recognized — alveolar and glandular. 
These forms take their origin from the surface epithelium or from 
pre-existing glands. In either form the wall of the cervix may 
be deeply infiltrated and the cervical canal filled. Ruge and Veit 
describe a budding process in the development of malignant gland 



358 SPECIAL DIAGNOSIS 

formations. Groups of epithelial cells bud from either side of the 
lumen of a gland and unite to form a bridge across the gland. Event- 
ually the lumen of the gland may be filled with epithehal cells. 

In no essential way does carcinoma of the cervix differ from 
carcinoma of the body of the uterus. 

III. Carcinoma of the Body of the Uterus. In carcinoma of 
the body of the uterus we see a great variety of histological forms. 
In general there are found the adenocarcinoma and the alveolar, 
very rarely the squamous-cell carcinoma. 

Adenocarcinoma may assume a type sometimes spoken of as 
malignant adenoma — i. e., a glandular growth in which the glands 
are greatly increased in number and invade the musculature. 
There is but a single layer of epithelium, and the glands are very 
irregular in outline and often increased in size. It is difficult to 
differentiate an early malignant adenoma from an advanced type of 
hyperplastic glandular endometritis, or what is sometimes called a 
benign adenoma. Gebhard describes two varieties of malignant 
adenoma — the everted form, in which the gland irregularities pro- 
ject outward from the lumen, and the inverted form, in which the 
irregularities project into the lumen of the gland. The two forms 
are often combined. 

When in addition to irregularity in outline and great increase in 
the number of the glands the epithelium proliferates to form two 
or more layers and the basement membrane is broken through, we 
have formed the adenocarcinoma. 

Alveolar carcinoma may form by the complete filling up of the 
gland lumen in the advanced stage of adenocarcinoma, or the sur- 
face epithelium may invade the underlying tissue, giving rise to 
the formation of ''cancer nests." 

Squamous-cell Carcinoma of the Body of the Uterus. There 
are but few authentic cases of squamous-cell carcinoma of the 
body of the uterus reported. To deny the possible existence of 
such growths, as does Cullen in his admirable work on Cancer of 
the Uterus, is unwarranted from a study of the recorded cases. 
That multiple layers of squamous epithelium of a perfectly benign 
character are found has been well established by Veit, Gebhard, 
Ries, and others. It is only reasonable to infer that such benign 
metamorphosis may in turn become transformed into squamous- 
cell carcinomata. 



PLATE LI. 
















Combination of Squamous-cell Carcinoma and Adeno- 
carcinoma of the Corpus Uteri. 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 359 

Zeller, in 1885, observed in the scrapings of all forms of endo- 
metritis isolated areas of stratified squamous epithelium showing 
none of the characters of a malignant growth. Gebhard and Menge 
made similar observations in gonorrhoeal endometritis. Werth 
examined the mucosa ten days after curettage, finding islets of 
squamous epithelium in the mouths of glands. Gottschalk and 
Winkler record similar observations in the endometrium of preg- 
nancy in the fifth and third months, respectively. Opitz and Geb- 
hard found small papillary elevations in the decidua, composed 
of three or four layers of squamous cells. Meier and Friedlander 
made observations on the uteri of foetuses and infants, in which 
they demonstrated isolated patches of squamous epithelium, four to 
six layers in thickness, the lowermost layer being cylindrical, the 
uppermost layer hornified, and the intermediate layer cubical in 
form. Heugge reports two cases, forty-four and forty-nine years 
of age, in which curettage was performed for the control of hemor- 
rhage. In both were found transformation and proliferation of 
the epithelium into stratified squamous epithelium, occupying the 
glands and the surface of the mucosa. 

In none of the above recorded cases was there evidence of malig- 
nancy. The benign metamorphosis occurred from the ninth month 
of fetal life to the forty-ninth year. Bebkiser, Hofmeier, and Geb- 
hard each described a case in which the benign stratified epithe- 
lium became transformed into a malignant squamous epithelial 
growth. Kaufman curetted the uterus of a woman, aged sixty- 
four years, who had suffered from uterine hemorrhage six years. 
In the scrapings were typical fields of adenocarcinoma, together 
with nests of squamous-cell carcinoma containing cancer pearls. 

It is probable, as Winter says, that these growths never arise 
directly from cylindrical epithelium. It is more likely that through 
mechanical, chemical, and myotic influences the cylindrical cells 
proliferate, become flattened, and subsequently undergo malignant 
transformation. 

Plate LI. is drawn from a specimen removed by Dr. J. Clar- 
ence Webster in the Presbyterian Hospital of Chicago. In the 
specimen is an interstitial fibroid of the uterine body lying directly 
posterior to a cauliflower growth of the endometrium. This endo- 
metrial growth is about two inches in diameter, is soft and friable, 
and shows no visible degenerative changes. The remainder of the 



360 SPECIAL DIAGNOSIS 

endometrium is apparently normal. Microscopic sections show an 
adenocarcinoma. Typical in form and intimately associated with 
malignant glands are areas of apparently squamous-cell carcinoma. 
In the field will be seen glands partially filled with flat epithelium, 
and cells showing transition stages from the cylindrical to the flat 
cells. No cancer pearls are found. After a thorough search through- 
out the endometrium not involved in the cauliflower growth, I 
could find no evident metamorphosis of the surface epithelium. 
It is probable that the existence of the flat epithelium may be 
accounted for by the presence of the encroaching fibroid — a result 
of pressure. 

I. THE DIFFERENTIAL DIAGNOSIS OF CARCINOMA OF THE 

UTERUS. 

Carcinoma of the vaginal portion of the cervix is to be dif- 
ferentiated from eversion of the mucous membrane, erosions of 
the cervix, decubitus, tuberculous, and syphilitic ulcers, follicular 
degeneration of the cervix, metritis coli, and sarcoma. 

Eversion of the mucous membrane of the cervix follows lacera- 
tion of the cervix. Viewing the cervix through a speculum, the 
eversion is often exaggerated by the traction made by the speculum 
upon the cervix. Grasping the two everted lips of the cervix with 
tenacula and bringing them together, the everted mucous membrane 
is rolled in, leaving a normal appearing cervix. The suspected 
portion is not friable and does not bleed freely when handled. 
Finally, if a section of the everted mucosa is examined under the 
microscope it is seen to be either normal or hypertrophied. There 
is no evidence of an epithelial invasion of the underlying tissue. 

Erosion of the cervix (mucous patch) may be confused with 
carcinoma when having a papillary surface or when deeply in- 
durated. Erosions seldom bleed so freely as does carcinoma, and 
the tissue is less friable. Where doubt exists a microscopic exami- 
nation of an excised piece of the suspected portion will confirm the 
diagnosis. No epithelial invasion will be found beneath the base- 
ment membrane. 

Decubitus ulcers of the cervix due to pressure from ill-fitting 
pessaries and friction of the cervix and thighs in prolapsus uteri 
are recognized by their punched-out appearance, the absence of 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 361 

hard, elevated margins, the granular bed in the absence of indura- 
tion, and, finally, by a microscopic examination of excised pieces 
of the ulcers in which there is found no epithelial invasion of the 
underlying structures. On removal of the pessary and replacing 
the prolapsed uterus, there is a tendency to healing which is never 
present in carcinomatous ulcers. 

Tuberculous ulcers of the cervix are rare as compared with 
carcinoma. A tuberculous family history, the presence of tuber- 
culosis elsewhere in the body, and particularly in the upper genital 
tract, will suggest the possible nature of the lesion. The tubercu- 
lous ulcer has a ragged, undermined margin in contrast to the hard, 
elevated margin of a carcinomatous ulcer. The bed of the ulcer is 
not indurated as in carcinoma, and may be studded with tubercles 
and covered with a yellowish secretion. Miliary tubercles may sur- 
round the margins of the ulcer. There is not the tendency to bleed 
when handled, nor is the tissue so friable as in carcinoma. Finally, 
a microscopic examination of excised pieces will reveal the tubercles, 
giant cells, and possibly the tubercle bacillus, and there will be an 
absence of deep invasion by the epithelium. There is a tendency to 
heal by cicatrization not seen in cancerous ulcers. 

Beyea speaks of ulcerative, miliary, papillary, and hyperplastic 
tuberculous endocervicitis. Papillary tuberculous endocervicitis, 
according to Beyea, is distinguished from a cauliflower carcinoma 
by the following: 

1. Not bleeding so freely or so early as carcinoma. 

2. More elastic and velvety and less friable than is carcinoma. 

3. Commonly occurring during the period of sexual maturity, 
while carcinoma occurs later. 

4. Great variations in history and in duration. 

5. Microscopic examination showing lesions typical of tubercu- 
losis and the absence of epithelial invasion. 

A S5rphilitic ulcer is single, shallow, and deeply indurated; the 
bed of the ulcer is covered with a grayish-yellow deposit, and the 
margins are not elevated but are described as serpiginous. The 
discharge is slight. There is a tendency to heal by cicatrization. 
Multiple ulcerated papules may be present. Under the micro- 
scope there is noted an absence of epithelial invasion of the cervix. 
Secondary syphilides assume the form of erosions and condylomata. 
There is usually an absence of induration and the lesions are mul- 



362 SPECIAL DIAGNOSIS 

tiple. These characteristics together with the history and the pres- 
ence of syphihtic lesions elsewhere in the body should render the 
diagnosis possible. 

Tertiary syphilitic affections of the portio are found in the form 
of gummata, more or less diffuse fibrosis, and ulcers. The ulcers 
may appear gangrenous and lead to confusion in the diagnosis. 
Nothing short of antisyphilitic treatment and a microscopic sec- 
tion of the ulcer can determine the true nature of the lesion. 

Follicular degeneration of the cervix, or what is commonly 
known as a follicular erosion, is described on page 301. The cervix 
may be considerably enlarged, irregular, and nodular. Cutting 
into the irregular elevations, inspissated mucus escapes. The 
suspected tissue is tough, not friable as in carcinoma, and does not 
bleed when handled. The microscope shows distended glands, 
with an intact, overlying mucosa not invading the underlying con- 
nective tissue. 

An interstitial fibroid of the cervix is commonly associated 
with similar growths in the body of the uterus. The tumor is firm, 
sharply circumscribed, and shows no tendency to friability and 
bleeding. On cross-section and under the microscope a fibrous or 
fibromuscular structure is seen. 

Metritis coli is a chronic inflammation of the cervix causing 
such thickening and hardening of the tissue as to suggest malignant 
infiltration. The enlargement is uniform as contrasted with the 
irregular growth of the carcinomatous cervix; there is an absence 
of the cartilaginous firmness of the cervix of the first stage of car- 
cinoma, and there is no bleeding on handling. In doubtful cases a 
section of the suspected tissue should be submitted to the micro- 
scope. 

Sarcoma of the cervix cannot be diagnosed from carcinoma 
without the aid of the microscope. The clinical history and the 
naked-eye appearance of the growth will not suffice for a diagnosis. 

Abel lately claims to have hit upon a valuable diagnostic point 
in squamous-cell carcinoma of the cervix. He finds by the Weigert 
resorcin-fuchsin stain the presence of elastic fibres surrounding the 
nests of the epithelium and running between individual epithelial 
cells. In benign epithelial growths, such as condyloma of the cer- 
vix and papillary erosions, elastic fibres are found at the margins 
of epithelial groups and do not run between individual cells. 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 363 

II. DIFFERENTIAL DIAGNOSIS OF CARCINOMA OF THE 

CERVIX. 

The differential diagnosis of carcinoma of the cervix is made 
from mucous polyps, submucous fibroids, and cystic degeneration 
of the glands of the cervix. In all of these the absence of friability, 
the slight bleeding when handled, finally, and conclusively, a micro- 
scopic examination of the suspected tissue, determine the diagnosis. 

III. THE DIFFERENTIAL DIAGNOSIS OF CARCINOMA OF THE 

BODY OF THE UTERUS. 

The differential diagnosis of carcinoma of the body of the uterus 
is from endometritis, submucous and interstitial fibroids, retained 
placental tissue, syncytioma malignum, hydatiform mole, arterio- 
sclerosis, sarcoma, and endometritis. 

Endometritis may closely resemble carcinoma of the body of 
the uterus in its clinical manifestations and in its macroscopic and 
microscopic appearances. 

The symptoms of endometritis may be identical with those of 
carcinoma. In both of these lesions all symptoms may be absent 
or so insignificant as not to concern the patient. 

A naked-eye examination of the endometrium after removal of 
the uterus or of scrapings removed from the uterus, while sufficiently 
characteristic in many cases, may be altogether misleading. It not 
infrequently happens that the only way to make a positive diagnosis 
is by the aid of the microscope. Indeed, it is only by an exploratory 
curettage and a microscopic examination of the scrapings that an early 
diagnosis of carcinoma of the uterus can be made. 

Carcinoma of the body of the uterus is so insidious in its development 
and so slow in its progress that it becomes imperative to regard with 
suspicion all hemorrhages, however slight, when occurring late in life, 
and to advise an exploratory curettage when the cause of the hemor- 
rhage, is not accounted for. 

In making a microscopic examination of suspected scrapings from 
the uterus we are to determine whether the glands are more irreg- 
ular in outline than the glands of hyperplastic and hypertrophic 
endometritis; whether they are so increased in number as to do 
away with the interglandular connective tissue to an extent not 



364 SPECIAL DIAGNOSIS 

observed in endometritis, and, finally, whether the epithelium is 
proliferated and broken through the basement membrane and is 
found within the interglandular connective tissue. These three 
findings — that is, great irregularity of the glands, great increase in 
number of the glands, and proliferation of the epithelium beyond 
the basement membrane — serve to distinguish adenocarcinoma and 
malignant adenoma from glandular endometritis. One, two, or all 
three of these features may be found, and are to be regarded as 
characteristic. The last, however, is by far the most reliable. 
Occasionally there will be found a specimen, the character of which 
cannot be determined with certainty. Such cases should either 
be treated as if malignant or should be kept under close observa- 
tion. 

Submucous and interstitial fibroids may present all the clinical 
evidences of malignancy. This is especially true in gangrene of 
the fibroid. Hemorrhage, leucorrhoea, pain, and emaciation may 
all be in' evidence, and suggest the presence in the uterus of a 
malignant growth. An exploratory curettage and a microscopic 
examination of the removed particles will establish a diagnosis. 

A fibroid bulging into the uterine cavity may be identified by 
sound, curette, or the examining finger. It is to be borne in mind 
that fibroids and carcinoma may coexist in the body of the uterus, 
and we are not to be content with the finding of any single cause 
for the symptoms, but are to exclude all possible causes. 

Retained Placental Tissue. Portions of the placenta may be 
retained in the uterus an indefinite length of time — weeks, months, 
and years after the termination of labor and abortion. Hemor- 
rhage, leucorrhoea, and pain may result, giving a clinical picture 
that may be mistaken for carcinoma of the body of the uterus. 
The lesion is most likely to be found during the period of sexual 
maturity, while the symptoms of carcinoma of the uterine body 
seldom appear before the climacteric period, and more often some 
time after the menopause. 

A positive diagnosis can only be made by an exploratory curet- 
tage and a microscopic examination of the scrapings. In recent 
cases the placental tissue may be recognized by the naked eye, but 
in cases of long standing mere shadows of placental tissue may be 
recognized by the microscope. The presence of decidual cells and 
chorionic villi in the scrapings determines the diagnosis. 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 365 

The glands of pregnancy are so varied and irregular in form 
as to suggest the possibility of malignancy where pregnancy has 
not been suspected. The interglandular connective tissue may be 
almost entirely lost by pressure of the enlarged glands. The glands 
seldom run at right angles to the surface and may run almost 
parallel. Their outlets are constricted by the surrounding decidual 
cells, while their deeper portions are widely distended. As a rule, 
a single layer of epithelium lines them, but more than one layer 
is occasionally found. The epithelium is flattened or cuboidal. K 
number of layers of flat epithelium have been observed in the 
glands. There is, however, no invasion of the interglandular con- 
nective tissue by the epithelium, and herein lies the differentiation 
from malignant glands. The finding of decidual cells surrounding 
the glands will suggest their character. 

Mucous polyps of the uterus are frequently the cause of hemor- 
rhage. While more common during the age of sexual maturity, 
they may be found at any age, even years after the menopause. 
The microscopic picture does not differ essentially from that of 
endometritis. The absence of epithelial proliferation and invasion 
of the underlying connective tissue will exclude carcinoma. 

The decidua of ectopic pregnancy may be confused with car- 
cinoma where pregnancy is not suspected. The scrapings from 
the uterus of an ectopic pregnancy may appear to the naked eye 
not unlike those from a carcinoma. Viewed under the microscope 
no doubt should arise. In association with the decidual cells are 
the glands of pregnancy, giving a picture not to be confused with 
carcinoma. 

Tuberculous endometritis may closely simulate carcinoma in 
its clinical and anatomical features. 

Tuberculosis of the endometrium usually occurs early in life as 
compared with carcinoma of the uterus. There may be a family 
history of tuberculosis, or tuberculous foci may be found elsewhere 
in the body. If found in the tubes, it is altogether probable that the 
endometrium will be involved. In exceptional cases the diagnosis 
can be made from cover-slip preparations of the leucorrhoeal dis- 
charge. To the naked eye the endometrium may present the char- 
acteristic ulcers and tubercles, but in general it may be said that 
in the absence of tuberculosis in other portions of the genital tract 
the lesion can only be diagnosed from endometritis or carcinoma 



366 SPECIAL DIAGNOSIS 

by microscopic examinations of sections taken from the uterus after 
removal, or from scrapings. The finding of tubercles, giant cells, 
or tubercle bacilli and the absence of epithelial invasion of the con- 
nective tissue will complete the diagnosis. The picture is distinctly 
that of an inflammatory reaction. 

DIAGNOSIS OF EXTENSION OF CARCINOMA OF THE UTERUS. 

It is of prime importance to determine whether or not the carci- 
noma is confined to the uterus. This should always be done before 
the diagnosis can be considered complete and before determining 
upon radical procedures in treatment. 

It is now generally conceded that the entire uterus must be 
removed for carcinoma involving any part of the organ; hence it is 
no longer a question as to how much of the uterus is involved in the 
growth, but rather as to whether it is confined to the uterus or has 
spread to the surrounding structures. We look to the parame- 
trium, vagina, bladder, rectum, lymph glands, and internal organs 
for secondary growths. 

The ^parametrium, particularly that portion of the cellular tissue 
found between the layers of the broad ligaments, is involved com- 
paratively early. In carcinoma of the cervix and vaginal portion 
the base of the broad ligament is invaded. The infiltrated tissue 
is felt as a ''board-like" mass, irregular and nodular in outline, 
firmly fixed, and not tender to pressure. The cervix is crowded in 
the opposite direction. 

The examination is best made under anaesthesia. Two fingers 
are placed in the rectum, the thumb in the vagina. Counter- 
pressure is made over the abdomen by the other hand. The cervix 
and area of infiltration will be found as one mass. The cervix will 
be immovable. This immobility of the cervix does not necessarily 
signify a carcinomatous invasion; it may well be inflammatory. 

Inflammatory swellings of the tubes and ovaries fixed by the side 
or behind the uterus may be mistaken for carcinomatous infiltration. 
Such swellings are more tender to pressure, are less cartilaginous 
in consistency, have not the same intimate connection with the 
cervix, and are commonly located on a higher plane. 

Still greater difficulty is experienced in differentiating carcino- 
matous infiltration of the parametrium from pelvic cellulitis. In 



DIAGNOSIS OF CARCINOMA OF THE UTERUS 367 

the latter there is greater tenderness, the outhne is flatter and less 
nodular, and there may be no direct and immediate connection 
between the carcinomatous lesion in the uterus and the infiltrated 
parametrium. The cervix is crowded away from the growth, while 
in parametritis the cervix is drawn to the infected side. 

It is difficult to demonstrate carcinomatous infiltration of the con- 
nective tissue occupying the vesicouterine space. Usually it is not 
possible until an incision is made into the region. The uterosacral 
ligaments may be infiltrated. The characteristics of the lesion and 
the differentiation from an inflammatory involvement of the same 
structures are as found in a like invasion of the broad ligaments. 

The vagina is invaded by direct extension, seldom by metastasis. 

Since carcinoma of the vaginal portion more often begins in the 
anterior lip, the anterior wall of the vagina is frequently first at- 
tacked. The infiltrated vaginal wall is readily recognized by the 
finger and by examination through the speculum. The infiltrated 
area in the vagina is directly continuous with the growth in the 
cervix. The margins of the infiltrated area are elevated, hard, and 
irregular. Ulceration follows in the late stage, and such ulcers 
show the irregular, elevated margins and the uneven base which 
bleeds freely on being touched. Metastatic growths may be found 
at any point in the vaginal walls, more often in the posterior wall. 
Such growths are hard and nodular, and may attain the size of a 
walnut. 

When the paravaginal tissue is infiltrated it is possible to move 
the vaginal mucous membrane independently of the underlying 
growth. 

Spiegelberg's sign is of some value in recognizing a carcinomatous 
infiltration beneath an intact mucous membrane. Passing the finger 
over the surface the mucous membrane feels like wet rubber, having 
lost its normal pliability. 

Invasion of the bladder is secondary to that of the anterior wall 
of the vagina. It is clinically recognized by frequent and painful 
urination, blood in the urine, and, finally, by the dribbling of urine 
into the vagina through a vesicovaginal fistula. An early diagnosis 
is made by a cystoscopic examination. The area of infiltration and 
the ulcers are distinctly detected, and when associated with advanced 
carcinoma of the cervix there can be no hesitancy in making the 
diagnosis of extension of the carcinoma to the bladder. 



368 SPECIAL DIAGNOSIS 

The rectum is invaded after the growth has spread to the pos- 
terior vaginal wall. The symptoms indicating invasion of the 
rectum are a mucous discharge which is often stained with blood, 
rectal tenesmus, constipation alternating with diarrhoea, and a dis- 
charge of feces through the vagina after the development of a recto- 
vaginal fistula. A digital exploration of the rectum and vagina 
reveals a hard, infiltrated area in the rectovaginal septum, which 
bleeds and may crumble to the touch; the mucous membrane of 
the rectum has lost its pliability, and cannot be moved indepen- 
dently of the underlying structures; and, finally, a section removed 
for microscopic examination determines the diagnosis. 

Metastatic growths are seldom early in making their appearance. 
Experience teaches us that it is never possible to say with absolute 
certainty that metastasis has not occurred even in the apparently 
early growths. The ovary is sometimes the seat of metastasis. Of 
the abdominal and thoracic viscera those most often involved are 
the lungs and liver. In carcinoma of the uterine body the lumbar 
glands are first involved. If the horn of the uterus is invaded the 
deep inguinal glands may be attacked by way of the round ligament. 
In carcinoma of the cervix, the vaginal portion of the cervix, and 
the upper segment of the vagina, the iliac glands lying in front of 
the sacroiliac synchondrosis at the bifurcation of the common iliac 
vessels are first invaded. 

In carcinoma of the vulva and lower segment of the vagina 
the inguinal glands are first attacked. It is of the greatest impor- 
tance to recognize involvement of the lymphatic glands in settling 
the question of operative interference. 

The diagnosis oj recurrence after removal of the uterus is of great 
importance. A recurrence implies failure in having thoroughly 
removed the primary focus. 

Winter speaks of local recurrence when the secondary development 
is in or near the previous field of operation; of lymph gland recur^ 
rence when the lymphatic glands of the body are involved subse- 
quent to the operation, and of metastatic recurrence when the 
carcinoma spreads by way of the blood stream to distant parts of 
the body. In the great majority of cases the recurrence is local 
and multiple. 

Hache gives the following statistics relative to the time of recur- 
rence of carcingnia after hysterectomy; 



DIAGNOSIS OF CARCINOMA OF THE UTERUS, 3^9 

Under three months ....... 19.4 per cent. 

Three to six months 18.0 " " 

Six to twelve months ....... 18.1 " " 

One to two years 22.3 " " 

Two to three years ........ 14.6 " " 

Over three years ........ 7.6 " " 

The above statistics were based upon a study of 144 cases. Pamard 
reports the return of a cervical cancer fifteen years after removal 
of the primary growth. We may state as a general rule, to which 
there are few exceptions, that recovery is assured after an interval 
of five years of freedom from recurrence. Early recurrence can be 
accounted for by the failure to completely remove all cancerous 
tissue in the primary operation. It is not so easy to account for 
the late recurrences. We may say that the cancerous foci have 
remained latent in the tissues throughout the intervening years, 
but such an assumption is scarcely tenable. That these late 
recurrences may be independent primary growths no one can 
deny. 

The great liahility of recurrence in carcinoma of the uterus admon- 
ishes us to always give a guarded prognosis, no matter how early and 
thoroughly the operation may have been performed. 

The general symptoms indicating a recurrence are loss of flesh 
and strength, cachexia, foul-smelling leucorrhoea, irregular hemor- 
rhages, and pain in the pelvis radiating to the thighs, groin, rectum, 
back, and abdomen. A positive diagnosis can only be made from 
a physical examination. Local recurrence in the tissues about the 
uterus is recognized by the cartilaginous consistency of the areas of 
infiltration in the vagina and broad ligaments. 

Granulation tissue in the scars at the end of the stumps may be 
regarded with suspicion. They are seldom so hard and friable as 
carcinoma, and a microscopic examination of an excised piece or 
scrapings will determine the diagnosis. It is not always possible to 
say of enlarged glands that they are so from carcinomatous involve- 
ment. It is possible that their enlargement is the result of infection. 

ENDOTHELIOMA. 

By endothelioma is meant a malignant new-formation arising 
from the endothelium of blood and lymphatic vessels and from 
serous surfaces. Endothelioma appears at any time in life. The 
earliest reported case is that of Braetz, at eighteen years of age. 

24 



370 SPECIAL DIAGNOSIS 

Such growths differ from carcinoma and sarcoma not only in 
their histogenesis, but also in their histological structure. 

In their gross appearance there is nothing distinctive. Under 
the microscope the lumina of blood and lymph spaces are seen to 
be distended with rapidly proliferating endothelium. The neigh- 
boring connective tissue and bloodvessels may be invaded. The 
individual cells assume a variety of shapes, and are not always 
recognized as endothelial in origin. The flat cells become irregular 
in outline and swollen, and the nuclei take a deep stain. It may be 
possible to identify these cells by tracing them to their origin in 
the walls of the vessels, where they are not so changed in structure. 

It is puzzling to differentiate between a carcinoma invading the 
lymph spaces and an endothelioma arising from the lymph spaces. 
In lymphatic carcinoma the appearance is that of veins of marble 
in the stroma. 



CHAPTEE XXIX. 

THE DIAGNOSIS OF SARCOMA OF THE UTERUS. 

Etiology. 
Anatomical Diagnosis. 

1. Vaginal Portion. 

2. Cervix. 

3. Body of the Uterus. 
Microscopic Diagnosis. 
Clinical Diagnosis. 

From the older literature we are led to believe that sarcoma of 
the uterus is an extremely rare condition. Roger Williams and 
Gurlt reported 10 sarcomata in 6764 tumors of the uterus. Doubt- 
less many sarcomata were regarded as carcinoma through failure to 
make a microscopic examination. Some were regarded as fibroids 
and were spoken of as recurrent. The growing frequency of re- 
ported cases is evidence of the discrepancies in previous reports. 

Whitridge Williams, in his Contribution to the Histology and 
Histogenesis of Sarcoma of the Uterus, reported 114 uterine sar- 
comata in the literature. The proportion of sarcoma to carcinoma 
of the uterus is said to be 1 to 40. 

ETIOLOGY OF SARCOMA OF THE UTERUS. 

Nothing is known of the essential cause of sarcoma. What has 
been said of Cohnheim's theory receives no confirmation in sar- 
coma. Inflammatory lesions and trauma seem to bear no causal 
relation, nor does childbearing. Fully two-thirds of the cases are 
found in women who either have not borne children or have given 
birth to less than the average number. We find no age exempt, 
from infancy to the postclimacteric period. A case has been lately 
reported in which a hysterectomy was performed at three years of 
age. Pick reports a case at two years of age. Hollander's case was 
seven months old when the disease was first discovered. The 

(371) 



372 



SPECIAL DIAGNOSIS 



oldest case recorded was seventy years. Gusserow reported seventy- 
three cases, of which four were under twenty-nine years of age; 
fifteen were from thirty to forty years; twenty-eight from forty to 
fifty; eighteen from fifty to sixty, and three were over sixty years of 
age. 



Fig. 155 




Fibi'osarcoma of the corpus uteri. A firm, rapidly growing tumor the size of a child's 
head protrudes from the vulva. Its attachment may be traced by a pedicle through the 
cervix to the fundus of the uterus. The tumor is not to be mistaken for inversion or 
prolapsus uteri, though either condition may be caused by the traction of the tumor. 



ANATOMICAL DIAGNOSIS OF SARCOMA OF THE UTERUS. 



As in carcinoma of the uterus, sarcoma is found in the vaginal 
portion of the cervix, in the cervical canal, and in the body of the 
uterus. 

1. Sarcoma of the Vaginal Portion of the Cervix. This is an 
uncommon location for sarcoma. To the naked eye there is no 
way of distinguishing this growth from carcinoma. There are the 
cauliflower and the infiltrating forms, resembling those found in 
carcinoma of the vaginal portion. 



DIAGNOSIS OF SARCOMA OF THE UTERUS 



873 



2. Sarcoma of the cervix is distinctive when assuming, as it 
usually does, a grape-like form (sarcoma botryoides). The mass 
protrudes from the external os and hangs into the vagina as trans- 
parent vesicles, appearing not unlike a vesicular mole. This form 
is more often found in childhood, but may appear in old age. 
Pfannenstiel found 50 per cent, in nulliparae. A similar growth is 



Fig. 156 




Sarcoma of the cervix. A tumor the size of a man's fist grew from the posterior lip of 
the cervix. It was of rapid growth, nodular, quite vascular, bleeding, and friable. It was 
a mixed-cell sarcoma. 



sometimes seen in the body of the uterus due to oedema or myxo- 
matous degeneration of the growth. Carcinoma of the cervix never 
assumes this vesicular form. 

Various heterotopic structures are frequently mixed with the 
sarcomatous tissue; these are cartilage, bone, epithelial elements, 
and mucous tissue. 

Sarcoma of the cervix may form a diffuse infiltration of the cer- 



374 SPECIAL DIAGNOSIS 

vical tissue or protrude from the surface as a tubercular, polypoid, 
or cauliflower growth. 

3. Sarcoma of the body of the uterus arises from any of the 
mesoblastic structures. Very commonly the growth is a malignant 
transformation of a pre-existing fibroid tumor. 

a. Sarcoma of the submucosa may take the form of a diffuse 
infiltration or of a papillary, polypoid, or nodular growth projecting 
from the surface. The surface of these growths is never shaggy as 
in carcinoma. The color varies from pale gray to dark red. Their 
consistency is soft and often friable. 

The growth rarely begins as a diffuse involvement of the mucosa, 
but rather as a circumscribed lesion extending by continuity of 
surface and by metastasis. 

b. Sarcoma of the wall of the uterus generally arises from sub- 
mucous or interstitial fibroids. The fibrous structure of the tumor 
gives place to a homogeneous substance of soft consistency, varying 
in color from pale gray to dark red. The growth is rapid as com- 
pared to that of a fibroid. Recurrent fibroids were recognized in 
the days when the microscope was little used. They are now 
regarded as fibrosarcomata. 

Sarcoma spreads through the uterine wall to the peritoneum and 
to the abdominal and pelvic viscera. Metastasis to neighboring 
organs and to lymphatic glands is unusual. The point of earliest 
attack is the lung. The ovary is the seat of secondary invasion 
more often in sarcoma than in carcinoma. 

MICROSCOPIC DIAGNOSIS OF SARCOMA OF THE UTERUS. 

As elsewhere in the body, sarcoma is classified as round-cell, 
spindle-cell, or giant-cell. Very often there is a mixture of these 
cells. 

1. Round-cell sarcoma is composed of large or small round cells 
having a large nucleus and a limited rim of protoplasm. The 
diameters of the cells vary from 4 to 15 micromillimetres. There 
is a variable amount of chromatin and an abundance of karyokinetic 
figures. Numerous newly formed bloodvessels are seen. The sar- 
coma cells directly bound blood spaces. 

2. Spindle-cell sarcoma is composed of large or small elongated 
cells arranged in bundles and bands. On section they appear in 



DIAGNOSIS OF SARCOMA OF THE UTERUS 375 

various forms from round to spindle. Two or more nuclei are 
observed. The amount of chromatin varies greatly. 

3. Giant-cell sarcoma is a rare finding in the uterus. These cells 
may be 80 micromillimetres in diameter. They are polynuclear, 
and are rich in chromatin and mytotic figures. The nuclei vary 
in shape and in staining qualities; vacuoles may be present. 

In all the above forms the fibrillar network may be so scanty 
that it escapes notice, or so abundant that the name fibrosarcoma is 
suggested. As a rule, the connective-tissue framework is distributed 
uniformly between the cells, but nests of cells may be surrounded 
by connective tissue, giving the appearance of cancer nests (alveolar 
sarcoma). Newly formed bloodvessels are prominent features of 
sarcoma, and may be sufficiently abundant to give to the tumor the 
name angiosarcoma. 

The intimate association of the blood channels with the sur- 
rounding sarcoma cells is characteristic. No sharp distinction can 
be made between the three microscopic forms. A mixture of two 
or three varieties of cells is the rule. 

Secondary changes in sarcoma tissue are of common occurrence, 
though not so frequent as in carcinoma, for the reason that sarcoma 
cells are more directly supplied with blood. Degenerative changes 
ordinarily begin in the centre of the sarcoma. The cells at the 
periphery do not usually suffer change. The degenerative forms 
commonly seen are the hemorrhagic, hyaline, and fatty. 

Mixed Tumors. The tendency of sarcoma cells to assume the 
mature type accounts for the frequency of the so-called myosarcoma 
of the uterus. Myxosarcoma is a myxomatous degeneration of the 
connective-tissue stroma. Enchondrosarcoma, carcinosarcoma, and 
melanosarcoma are of extremely rare occurrence. 

CLINICAL DIAGNOSIS OF SARCOMA OF THE UTERUS. 

All that has been said of the clinical diagnosis of carcinoma of 
the uterus applies to sarcoma. The clinical manifestations and 
physical findings do not materially differ from carcinoma. The 
differential diagnosis of carcinoma from sarcoma must depend upon 
the microscope. 

The early recognition of sarcomatous degeneration of a 
fibromyoma is of the utmost importance. When a fibromyoma of 



376 SPECIAL DIAGNOSIS 

the uterus undergoes malignant changes it takes on rapid growth, 
becomes softer in consistency, more pain is experienced in the 
region of the tumor, cachexia rapidly develops, ascites may make 
its appearance, and metastatic growths may arise in the lungs and 
elsewhere. If the tumor is interstitial or submucous, the hemor- 
rhages will be greater. When a fibroid takes on a rapid growth, 
particularly if near the time of the menopause, no time should 
be lost in removing the growth. When after removal of a fibroid 
the growth returns, it is suggestive of sarcoma. 

The length of time a sarcoma may exist before destroying life is 
variable, and has been observed from two months to five years. 
The average time is estimated at two years. 



.CHAPTER XXX. 

THE DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES. 

Methods of Examination. 

Anomalies in Structure. 

Change in Position. 

Circulatory Disturbances. 

Inflammations and Infectious Granulomata. 

New-formations. 

Methods of Examination. Only under favorable conditions 
can a normal tube be outlined in a bimanual examination. If 
the abdominal walls are thick and tense an anaesthetic will be 
required. 

The uterus is first located in an abdominovaginal examination. 
From the horn of the uterus the hand, passing outward toward the 
sides of the pelvis, should follow the tube a variable distance. The 
normal tube is made to roll under the examining finger like a cord. 
It appears to be about the size of a slate-pencil. At the fimbriated 
extremity the wall is so thin that it is impossible, under normal 
conditions, to palpate it. When the uterus is in retroposition, or 
when the tubes have fallen behind the uterus, or when the uterus 
and tubes are in their normal position and the vagina is small and 
sensitive, the rectoabdominal method of examination is preferable. 
In the unmarried a rectoabdominal examination should be done 
under anaesthesia. 

Where the tubes lie beyond easy reach of the examining finger, 
traction upon the cervix with vulsella forceps should be made by an 
assistant, while the rectoabdominal or vaginoabdominal method is 
carried out. 

May a sound be passed into the tube? Undoubtedly the sound 

has been passed into diseased tubes, but it is questionable whether 

the normal tube has ever been sounded. It is very certain that the 

procedure should never be attempted for fear of penetrating the 

uterus. 

( 377 ) 



378 SPECIAL DIAGNOSIS 

ANOMALIES IN THE STRUCTURE OF THE TUBES. 

1. Both tubes may be wanting, in which case the uterus is com- 
monly absent. 

2. A single tube may be wanting, in which case the corresponding 
side of the uterus is usually absent. 

3. One or both tubes may be rudimentary and associated with a 
rudimentary uterus. The tubes may remain infantile in type, very 
greatly convoluted, and have a small lumen. 

4. The lumen of the tube may be partially or completely oblit- 
erated or may be abnormally large. 

5. Rudimentary tubes or fimbriae may spring from the main 
tube. Leading into the main tube through the accessory tubes and 
fimbriae are rudimentary canals and ostia. 

Webster resected the fimbriated end of the tube; some months 
later the abdominal cavity was again opened and the fimbriae were 
found to be regenerated. 

6. Diverticula of the endosalpinx are sometimes present, and are 
known to be a cause of tubal pregnancy. 

CHANGES IN THE POSITION OF THE TUBES. 

These changes may be congenital, but are more often acquired. 
In congenital malposition of the tubes there is usually a malposi- 
tion or maldevelopment of the uterus. In a uterus bicornis the 
tubes lie more to the sides of the pelvis than is normal. In a rudi- 
mentary uterus the tubes lie below the normal level. Congenital 
hernia of one or both tubes is a rare finding. 

Much more frequent are acquired displacements of the tubes. 
When the tube becomes enlarged and increased in weight, it tends 
to fall to a lower level at the side of or behind the uterus. Adhe- 
sions may pull the tube in any direction, and all swellings, whether 
inflammatory or new-growths, push the tubes into malpositions. 
Any displacement of the uterus will almost invariably displace the 
tubes. 

CIRCULATORY DISTURBANCES IN THE TUBE. 

Whatever interferes with the general or local circulation in the 
pelvis may cause congestion of the Fallopian tubes. Thus diseases 



PLATE LII. 

FIG. 1. 



i ^ 



FIG. 2. 



-/■<^^i;kv^^ 






.(^r^o 



J c 



» 



--n:-;' 






FIG. 3. 






^^'"^'^ - %. 


















'--2 







Fig. 1.— Cross-seetion of the Interstitial Portion of the Fallopian Tube. 
Fig. 2.— Cross-seetion of the Infumdibuilar Portion of the Fallopian Tube. 
Fig. 8.— Cross-seetion of the Ampullar Portion of the Fallopiaia Tube. 



DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 379 

of the heart, lungs, liver, and kidney, abdominal tumors, ascites, 
chronic constipation, and tight lacing are among the causes of tubal 
congestion. 

Infectious diseases, the blood dyscrasias, burns, toxaemias, and 
menstrual congestion are additional general causes. A displaced 
tube, one that is twisted, constricted, or compressed, may cause 
congestion and possibly hemorrhages of the tube. 

Anatomical Diagnosis. The congested tube is slightly swollen, 
dark red in color, and offers unusual resistance to pressure. Hemor- 
rhages may be seen in the mucosa and in the lumen. Necrosis of 
the tube may result from interference with the blood supply. Martin 
describes a case of necrosis of the tube following a mitral insuffi- 
ciency. 

When the ends of the tubes are closed and blood is extravasated 
into the lumen in sufficient quantity, the tube will be distended 
into what is known as a haematosalpinx. For further description 
of hsematosalpinx see page 395. 

The microscope shows the vessels to be deeply congested with 
blood extravasated into the tube wall and lumen. When there is 
necrosis the tissues stain poorly. 

Clinical Diagnosis. Perhaps a large proportion of cases goes 
unrecognized, partly because of the frequency with which the 
lesion exists in the absence of all clinical manifestations; partly 
because of associated lesions. The menstrual periods are painful, 
and the functions of the bowel and bladder are performed with 
more or less discomfort. Tenderness on pressure over the affected 
tube is the one constant symptom. The diagnosis cannot be made 
with certainty without an exploratory incision. The existence of 
a possible cause, together with the finding of a tube that is some- 
what tender to pressure and slightly enlarged, will lead to a prob- 
able diagnosis. It is manifestly impossible to differentiate clinically 
a congested tube from a catarrhal salpingitis; the former is the 
forerunner and accompaniment of the latter. 

The diagnosis of hsematosalpinx will be referred to on page 395. 

INFLAMMATIONS AND INFECTIOUS GRANULOMATA. 

General Considerations. Of all lesions of the tube the inflam- 
matory are most commonly observed. Of the various exciting 



380 SPECIAL DIAGNOSIS 

causes of salpingitis we have the authority of Noeggerath and 
Wertheim for placing the gonococcus at the head of the list of 
micro-organisms. In 302 cases of inflammatory lesions in the 
tubes, there were 83 in which living micro-organisms were found, 
and of this number 56 were gonococci, 11 were streptococci, 6 were 
staphylococci, 1 was the pneumococcus, while 122 were sterile. The 
fact that such a large percentage were sterile adds to the difficulty 
in determining the essential microbic cause. L. R. Guthrie col- 
lected statistics from operators in fifteen cities of Iowa, and con- 
cludes that 70 per cent, of inflammatory diseases of the tubes are 
of gonorrhoeal origin. Neisser, in 143 cases, found the gonococcus 
in 80 after a latent period of from two months to eight years. He 
emphasizes the necessity of repeated examinations and faultless 
technique. Mixed infections are of common occurrence. 

The path of invasion is usually by way of the uterus ; seldom 
by the abdominal route from the ovary, bowel, and peritoneum. 
More rarely is the invasion by way of the lymph and blood 
streams. 

The manipulation of an infected uterus during the process of an 
examination or operation is doubtless often responsible for exten- 
sion of the infection from the uterus to the tubes. 

There are no pathognomonic symptoms of salpingitis, and none 
that are invariably present. Associated inflammatory lesions in 
the genital tract are nearly always found, and hence it is that the 
symptoms of the one are so intimately associated with those of 
the other, and, therefore, it is difficult to obtain a clinical picture 
of salpingitis. 

Again, the innervation of the tubes, ovaries, and uterus is so 
intimately connected as to bring these organs into close sympathy 
one with the other. 

Pain is the most constant symptom, and yet advanced cases of 
salpingitis exist in the absence of pain. Temperature has but little 
diagnostic value. Sterility does not necessarily follow as the result 
of double salpingitis, though it is the rule. An occluded lumen 
may eventually become patent and permit the passage of the 
ovum. 

The history of infection and the clinical course of the disease 
cannot in themselves suffice for a diagnosis, but must be supported 
by direct palpation of the diseased tubes. 



DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 381 

CLASSIFICATION OF SALPINGITIS. 

I. Catarrhal -Salpingitis. 

1. Acute catarrhal salpingitis (endosalpingitis). 

2. Chronic catarrhal salpingitis. 

a. Salpingitis isthmica nodosa. 
End stages: 

a. Hydrosalpinx. 
h. Hsematosalpinx. 
II. Purulent Salpingitis. 

1. Acute suppurative salpingitis. 

a. Septic. 

1. Puerperal. 

2. Non-puerperal. 
h. Gonorrhoeal. 

2. Chronic suppurative salpingitis. 
End stage: Pyosalpinx. 

HI. Tuberculous Salpingitis. 

I. Catarrhal Salpingitis. 

Etiology. The statistics of Martin illustrate the frequency of 
the lesion. In 1402 operations on the tubes 415 (29.5 per cent.) 
were for catarrhal salpingitis. 

As a rule, the lesion is secondary to inflammatory diseases of the 
uterus, which extend by direct continuity of tissue. Primary 
catarrhal salpingitis, in the absence of an inflammatory lesion else- 
where in the pelvis, is an unusual occurrence. 

We may speak of the causes as thermic, mechanical, chemical, 
and microbic. 

1. Thermic influences resulting in salpingitis can scarcely act 
directly because of the deep-seated location of the tube. Menstrual 
congestion from chilling of the body may be placed in this category. 

2. Mechanical causes have a greater significance. Such, for 
example, are digital and instrumental manipulations, sexual ex- 
cesses, massage, and overstrain in lifting and walking. 

3. Chemical irritants in the form of antiseptics injected into the 
uterus may pass into the tubes and set up a salpingitis. 

4. By far the most essential and prevailing factors in the causa- 
tion of catarrhal salpingitis are the pathogenic micro-organisms. 



382 SPECIAL DIAGNOSIS 

It is not always possible to distinguish between the above-named 
causes in a given case of catarrhal salpingitis. Two or more factors 
may operate to bring about the same result. Of the general dis- 
eases complicated by catarrhal salpingitis mention may be made 
of all the specific, infectious, and contagious diseases, notably 
tuberculosis, malaria, and chlorosis. 

Anatomical Diagnosis. In acute catarrhal salpingitis the tube 
is of a livid or dark-red color, is slightly thickened and convoluted, 
its consistency is increased to a limited degree, and the fimbriae are 
red, swollen, and retracted to a variable degree preparatory to a 
possible closure of the abdominal end of the tube. On cross-section 
of the tube the mucosa rolls out and is congested and thickened. 
In the lumen of the tube is a variable amount of serous fluid. No 
adhesions surround the tube. 

Fig. 157 




Chronic catarrhal salpingitis. The tube is about double the normal size. Its course is 
irregular, and the serous covering is congested. The fimbriae are swollen, but do not 
occlude the abdominal opening of the tube. 

The microscopic diagnosis is based upon the marked congestion 
and infiltration with small round cells in the mucosa, and to a less 
degree in the musculature. Here and there are hemorrhagic extrav- 
asations into the connective-tissue spaces. The epithelial lining 
of the tube lumen may be normal, but in long-standing lesions the 
cells may degenerate and become desquamated. The secretion 
found in the lumen of the tube is in great part lymph mixed with 
blood cells and degenerated epithelium. From the acute stage the 
tube may easily resolve into a normal condition, suppuration may 
follow, or, as is not infrequently the case, the acute stage may pass 
into the chronic. 

In chronic catarrhal salpingitis the tube enlarges in all diameters 
and is correspondingly convoluted. The tube is of firmer consist- 
ency than in the acute stage. The mucosa and muscularis are 



DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 383 

thickened through congestion of the bloodvessels and hyperplasia 
of the connective tissue. The epithelium lining the tube lumen 
may be destroyed. Following this the lumen may be obliterated 
by adherence of the denuded mucous folds. Adjacent folds of 
mucous membrane may adhere by their free margins and lock 
in spaces filled with a serous secretion and lined with columnar 
epithelium, thereby closely simulating retention cysts formed from 

Fig. 158 






. uL" 'ui,; VI ^y. ■ ^ .^. ,;'**^«a.,^ 







^^ 



%3^^ 



Mr^- 



r- /- 



'^..r-' 



-^^-- - Oi'Vv'. VAhrer. 



Catarrhal salpingitis. The villous projections of the mucosa are club-shaped, congested, 
and infiltrated with small round cells. The muscularis is congested. 

glands. The mucous folds become club-shaped from conges- 
tion and the inflammatory exudate. The peritoneal covering 
of the tube is involved, and adhesions may surround the tube 
and close up the fimbriated end, leading to the formation of a 
hydrosalpinx. 

Salpingitis isthmica nodosa is regarded by Chiari and Schauta as 
a circumscribed interstitial salpingitis located in the isthmus of the 
tube and forming a nodular enlargement varying in size from that 



384 



SPECIAL DIAGNOSIS 



of a split pea to a bean. Gebhard regards these growths as benign 
adenomata. 

Hydrosalpinx (sactosalpinx serosa) is the end stage of catarrhal 
salpingitis. The ends of the tube become closed and the pent-up 
secretion distends the tube into a serous sac. Because the thin, 
distended, fimbriated end of the tube offers little resistance to 
the accumulating fluid, the tube distends at the outer end to a far 



Fig. 159 




Hydrosalpinx. The tube is distended with serum into an irregular retort-shaped mass 
the size of a fetal head. The wall of the cyst is thin and transparent. The uterine end 
of the tube is not distended. A normal ovary lies adherent to the distended tube. 
(Specimen removed by Dr. J. Clarence Webster.) 



greater extent than at the uterine end, where the muscular wall is 
more resistant and the lumen of the tube smaller. It is unusual 
for the tube to distend throughout its entire length; it may enlarge 
to the size of a child's head. The larger the tube the thinner and 
more transparent is the wall. 

Adhesions to the tube are not ordinarily present, and are seldom 
firm, hence hydrosalpinx is more or less movable, The fimbriated 



PLATE LIII. 




Hydrosalpinx. 

A branching fold of mueous membrane projects into the lumen 
of the tube. It is composed, of connective tissue covered by a single 
layer of columnar epithelium. A section of the tube w^all is com- 
posed of connective tissue, muscle fibre, and bloodvessels; and is 
lined -within by a single layer of columnar epithelium. 



DIAGNOSIS OF BISUASES OF THE FALLOPIAN TUBES 385 

end is shaped like a club or retort. Radiating lines mark the adhe- 
sions of the fimbrise. • 

In the early stage we have the gross and microscopic appearance 
of catarrhal salpingitis. As the tube distends the walls become 
thinner and more transparent; the mucosa thins and the muscula- 
ture is stretched and atrophied, presenting longitudinal bands of 
muscle fibres running the entire length of the tube and terminating 
at the fimbriated end in a rosette figure. 

The epithelium of the mucosa is compressed and may be wholly 
lost. The contents of the tube is clear, serous fluid, with a specific 
gravity of 1005 to 1010, and an alkaline or neutral reaction. Some- 
times the fluid is of a greenish tint, due to the presence of cholesterin. 
Desquamated epithelium, leukocytes, and occasionally a few red 
blood cells are found in the fluid contents of the tube. 

When the uterine end of the tube is not permanently and com- 
pletely closed the contents may be periodically discharged into 
the uterus (hydrops tuhoe profluens). As expressed by Sutton, the 
blockade at the uterine end has been raised. 

The contents of the tube may be absorbed, but it is unusual for 
the fimbriated end to reopen. 

A pyosalpinx may develop from a hydrosalpinx by secondary 
infection with pyogenic organisms conveyed through the uterus or 
bowels. Torsion of a hydrosalpinx is a possible event leading to 
the formation of a hsematosalpinx. 

Sutton gives the following reasons for believing that a pyosalpinx 
often resolves into a hydrosalpinx: 

1. Hydrosalpinx is not found in acute cases. 

2. In many chronic cases hydrosalpinx is found on one side of 
the uterus and pyosalpinx on the other. 

3. The ampulla of a tube will sometimes be dilated into a hydro- 
salpinx, while the isthmus contains pus. 

4. The fluid contents in a hydrosalpinx will sometimes be color- 
less, but the recesses of the tube contain caseous material and 
cholesterin. 

5. The dilated tube in the hydrosalpinx may, as in pyosalpinx, 
communicate with a large ovarian follicle to form a tubo-ovarian 
cyst. 

Tubo-ovarian Cyst. Here the ovary is distended into a cyst which 
communicates with a hydrosalpinx through an adventitious open- 

25 



386 



SPECIAL DIAGNOSIS 



ing. A congenital tubo-ovarian cyst has not as yet been described. 
As a rule, the hydrosalpinx and ovarian cyst develop independently. 
Later the two structures unite by adhesions, the partition wall 
atrophies, gives way, and there is established a communication 
between the two. Rokitansky described a corpus luteum cyst 
communicating with a hydrosalpinx. 

The fimbriae of the tube may be found free in the ovarian cyst or 
adherent to the inner surface of the cyst wall. 



Fig. 160 




Tubo-ovarian cyst. 

Haematosalpinx. From the macroscopic appearance it is not 
always possible to distinguish an inflammatory haematosalpinx from 
one due to ectopic pregnancy or to other non-inflammatory causes. 
The wall of the tube is possibly thicker from round-cell infiltration 
and hyperplasia, and infiammatory adhesions may form about the 
tube. In addition there are usually evidences of infection in the 
uterus. A careful study of specimens of haematosalpinx will, in a 
large percentage, lead to the discovery of an embryo, an apoplectic 



DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 387 

ovum, or chorionic villi. It is the uniform testimony of observers 
that nearly all cases of haimatosalpinx are due to ectopic gestation. 

The term hcematosal'pinx should be reserved exclusively for 
Fallopian tubes dilated with blood and in which there is no evi- 
dence of pregnancy. A dilated tube containing chocolate-colored 
fluid is not to be classed as hsematosalpinx. 

The gross and microscopic appearances of hsematosalpinx do not 
differ greatly from those of hydrosalpinx, with the exception of the 
contents and the dark-red color which is imparted to the contents. 
Fluctuation may not be so distinct in haematosalpinx. 

Clinical Diagnosis of Catarrhal Salpingitis. 1. Acute Catar- 
rhal Salpingitis. The clinical picture is usually that of uterine 
catarrh or of acute pelvic inflammation. Rarely are the tubes 
alone involved, and hence it is difficult to clearly define the clinical 
signs of catarrhal salpingitis. There is a feeling of weight and 
discomfort in the pelvis, often amounting to acute pain, which is 
located in one or both sides. Painful urination and defecation are 
sometimes complained of. (See Plate LIV., Fig. 1.) 

The initial chill, followed by a rise of temperature, which is 
accompanied by flashes of heat and cold, may be due to the sal- 
pingitis, but is more often the result of more extensive lesions in 
other parts of the pelvis. 

It is possible for catarrhal salpingitis to exist without the knowl- 
edge of the patient. 

The diagnosis must, therefore, rest largely upon the local findings, 
for in the absence of a physical examination no positive diagnosis 
can be made. Because of pain and tenderness the tubes cannot be 
palpated without an anaesthetic. The tube as outlined in a bimanual 
examination is about the size of the little finger; it is movable, 
slightly more resistant to pressure than is the normal tube, and 
at the fimbriated end the sensation imparted is that of a soft, 
ill-defined mass. 

2. Chronic catarrhal salpingitis may arise in a very insidious 
manner, or may begin as an acute infection, with all the symptoms 
and signs above referred to. In the chronic stage there is no tem- 
perature and no increase in the pulse rate. The patient is often 
nervous, and suffers from pain, particularly during the menstrual 
periods. Sexual intercourse is painful, and a leucorrhceal discharge 
is a common accompaniment. 



388 



SPECIAL DIAGNOSIS 



In the form described by Chiari and Schauta, known as salpingitis 
isthmica nodosa, the pain during menstruation is cohcky and cramp- 
ing. The tenderness on palpation is not so great as in the acute 
stage. The tube is outlined as irregular, convoluted, and of the 
size of the thumb or index finger. In consistency the tube is much 
firmer than normal, and in manipulating the tube the range of 
motion is observed to be restricted, in part from loss of flexibility, 
and in part from the presence of adhesions about the tube. The 
position of the tubes is seldom exactly normal. More often they 
are found at the side of or behind the uterus. The uterus may be 
drawn to the affected side and restricted in its range of motion. 



Fig. IGl 




Large hpematosalpinx; semidiagrammatic. (Thomas and Munde.) 



In salpingitis isthmica nodosa the nodular swellings near the 
horn of the uterus are sometimes recognized in a bimanual examina- 
tion. Few cases have been diagnosed clinically. 

Hydrosalpinx and hsematosalpinx are recognized clinically by 
the pressure they make upon the surrounding structures and by 
direct palpation. The patient may be wholly unaware of the exist- 
ence of the lesion. 

In a conjoined examination, preferably under anaesthesia, the 
distended tube is outlined as a retort-shaped mass, tense, elastic, 
and often fluctuating. If no adhesions surround the tube there 
should be a free range of motion. The small and firm uterine end, 
together with the outer, rounded, elastic, and fluctuating portion, 
gives the impression of an ovarian cyst. The ovary can rarely be 
recognized apart from the distended tube. There is no way of 



DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 389 

detecting a hydrosalpinx *from a hsematosalpinx except by aspirating 
or by an exploratory incision. 

Tubo-ovarian cysts are only recognized after the cyst is removed. 

Fig. 162 




Right tubo-ovarian abscess and left pyosalpinx. The right tube and ovary are distended 
with pus, as is also the left tube. Adhesions bind the tubes together and the right tube to 
the posterior surface of the uterus, rectum, and wall of the pelvis. 

II. Purulent Salpingitis. 

Etiology. The causes are essentially those of catarrhal salpingitis. 
As previously stated, catarrhal salpingitis may be followed by sup- 
puration. On one side may be a catarrhal salpingitis ; on the other 
side a purulent salpingitis; the two apparently distinct and separate 
lesions may be dependent upon the same cause. 

Following are the statistics from the clinic of A. Martin: In 
2098 cases of purulent salpingitis, 279 were caused by gonorrhoea, 
374 by puerperal septic infection, 19 by tuberculosis, and 13 by 
syphilis. Of this number 1282 were preceded by catarrhal sal- 
pingitis. From the statistics of Martin, Schauta, Frommel, Char- 
rier, Wertheim, and Prochowick 376 cases are collected, and of 
this number, 76 showed a pure culture of the gonococcus, 10 a mixed 
gonococcus infection, 15 a staphylococcus and streptococcus, 7 a 
pneumococcus, and 3 a bacterium coh infection. In 15 there was 
doubtful identity, and in 215 the tubes were sterile. 

In puerperal septic infection the essential causes are, in the order 
of frequency, staphylococcus pyogenes aureus and albus, and strep- 



390 SPECIAL DIAGNOSIS 

tococcus pyogenes. The gonococcus, the tubercle, and colon bacilli 
are occasional factors. 

The infection commonly travels by direct continuity of tissue, 
passing directly from the endometrium to the tube. Occasionally 
the infection is conveyed through the broad ligaments to the tube, 
or from the peritoneum to the tube. 

Infection of the tubes acquired by instrumental and digital 
manipulations is due to the same sort of bacteria as are found in 
puerperal infection. 

Gonorrhoeal infection of the tube is for the most part acquired by 
sexual intercourse, but may be conveyed by instruments and the 
fingers both in the puerperal and non-puerperal state. The infec- 
tion usually travels by continuity of tissue, but may be conveyed 
by the lymph and blood streams. 

Anatomical Diagnosis, a. In acute purulent salpingitis there are 
all the evidences of an intense acute inflammation. The tube is 
enlarged possibly to the size of the thumb; the color is an intense 
red; the distended bloodvessels stand out prominently under the 
serous covering, and the fimbriae are swollen and retracted. Very 
early in the process the fimbriae may be agglutinated, thereby com- 
pletely closing the abdominal end of the tube. These adhesions 
are not firm, and for this reason the bimanual examination must 
be made cautiously for fear of expressing the pus from the tube into 
the abdominal cavity. From the naked-eye appearance of the 
unopened tube it is impossible to say whether or not there is pus 
within the lumen. (See Plate LIV., Fig. 2.) 

In the acute stage a fresh fibrinous exudate forms about the 
tube, and as the lesions pass into the chronic stage these adhesions 
extend and become more firmly organized. The elongation of the 
tube leads to kinking and convolutions in the course; the tube 
may be completely doubled upon itself. In the lumen of the tube 
pus is accumulated in varying amounts. 

Under the microscope the tubal wall is seen to be congested, and 
there is round-cell and leukocytic invasion of its entire wall. Pyo- 
genic micro-organisms can be demonstrated throughout the wall. 
The epithelium of the mucosa is early destroyed, and the folds of 
denuded mucous membrane adhere, thereby partially or com- 
pletely obliterating the lumen of the tube and locking in spaces 
filled with pus. Throughout the muscularis and underneath the 



PLATE LIV/ 
m 

Tig I -f-^ 



i^- 



a 




.».-*•*'■. 




FiffS. 






OD 

Fig. I. — a, Salpingitis Catarrhalis Haeiriorrhagica, Cross-section: w, muscle of the tube. 
n, mucosa of the tube. /, lumen of the tube. Picrocarmine stain. (Hartnack, Oc. 2 ; Objec- 
tive 4.) h, leukocytes containing blood pigment with normal red blood corpuscles from the 
tubal mucosa. (Hartnack, Oc. 2; Objective 7.) 

Fig. 2. — Salpingitis Purulenta Acuta Dextra: ou, uterine opening of tube, oa, abdominal 
end of tube, ov, right ovary. /, purulofibrinous deposit. Posterior view, natural size. 

Fig. 3. — Salpingitis Purulenta Chronica Dextra: ou, uterine end of tube, oa, region of 
abdominal end of tube, ov, ovary with strongly adherent tube. Posterior view, natural size. 



1 August Martin, Krankheiten der Eileiter. 



DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 39I 

serous covering are localized areas of suppuration. In the pus 
accumulated in the lumen and wall of the tube it is often possible 
to demonstrate the presence of the micro-organisms causing the 
infection. The older the infection the less likely is the finding of 
bacteria. There may be superficial necrosis of the mucosa forming 
a pseudodiphtheritic membrane. Gonorrhoeal infection is more 

Fig. 163 



•7— T— 5 5—, .m— . — ^Uv" V "f »m "^ "■* """S^ — -! — 












,^^ 



.^^" 






"t fi-i&r 4 



\ 



u .'t 



J^< VC. ^ 55 ^^. '»* >, .«» __ _ -^'- „ v;.,, 






^ i* 



»»« 



1^, \'r .^^v.- - v^" ,>j., ^--/ 'i^ : ,^- -- -f^ 

^ ' * ^' >^x ^ * 






/ 



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Aj ». __ . ^ N L •" 



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Acute purulent salpingitis. The folds of mucous membrane are swollen and club-shaped ; 
they are infiltrated with small round cells, pus cells, and pyogenic micro-organisms. A 
similar infiltration is found in the muscularis. In the lumen of the tube are found blood 
and pus cells in all stages of degeneration. The epithelium is intact. 

likely to be confined to the mucous membrane than are the other 
forms. Wertheim demonstrated the presence of the gonococcus in 
all portions of the tube. 

b. In chronic purulent salpingitis the tube attains to about the size 
of the thumb. The color is not such an intense red as in the acute 
stage, and the adhesions are firmer and more extensive. The fim- 
briae are almost invariably adherent, obliterating the abdominal 



392 SPECIAL DIAGNOSIS 

end of the tube. The convolutions of the tiibe are bound one to 
another, and are adherent to the ovary, uterus, bowel, bladder, 
omentum, and abdominal wall. These adhesions permit very 
limited excursions of the tube. As the tube enlarges and the adhe- 
sions contract the tube and ovarv adhere to the side of or behind 
the uterus. The appendix vermiformis and tube are so frequently 
adherent that it is always advisable to inspect the appendix when 
the abdomen is opened. From the tube the pus may evacuate 
through adhesions into an adherent hollow viscus. Again, the 
infection may travel from the bowel through the adhesions to the 
tube and cause a secondary infection in the tube. (See Plate 
LIV., Fig. 3.) 

Fig. 164 



^^^^^^^B^mUhI 


&;'"'** 




V 

" 


/ if/ • 


fj'' 




mJ 




^ 



Gonorrhoeal metritis, double pyosalpinx, and ovarian abscess. The uterus is uniformly 
enlarged and firm. The tubes are retort-shaped, and are matted to the distended ovary and 
sides of the uterus. 

The pus within the tube is yellow or grayish-yellow, rarely greenish 
or blood-stained. Nothing can be ascertained from the naked-eye 
appearance of the pus as to its virulence. In long-standing cases 
the formed elements of the pus may absorb, leaving a serous fluid. 

The entire wall of the tube is thickened through congestion and 
hyperplasia of the connective tissue. Small abscesses may be seen 
in the mucosa, the muscularis,- and underneath the serosa. 

Pyosalpinx (sactosalpinx purulenta). Where the ends of the tubes 
are closed the pus accumulates within the lumen and distends the 
tube. The greater distention is at the fimbriated end, where the 
wall is thin. It is seldom that the tube is distended throughout 



DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 393 

its entire length. The size is seldom greater than a man's fist, but 
it may be large enough to extend above the brim of the pelvis and 
even to the umbilicus. The wall of the tube is at first thickened, 
but when greatly enlarged there is an irregular thinning, even to 
the point of rupture. Rupture of the tube may take place at its 
lower circumference between the layers of the broad ligament or 
at any point in the wall of the tube. Adhesions usually protect 
the peritoneal cavity, and frequently direct the pus into a hollow 
viscus or into a cyst of the ovary. Left pyosalpinx is very prone 
to rupture into the rectum. 



Fig. 165 




The left tube is distended with pus and is adherent to the posterior surface of the uterus. 
The right tube and ovary are normal. 

The pus contained within the distended tube is found in various 
stages of preservation, and is mixed with red blood cells, degen- 
erated epithelium, fibrin, and detritus. The mucosa atrophies from 
pressure, and may be replaced by connective tissue. The epithelium 
is almost wholly destroyed. The muscle and connective tissue 
fibres are atrophied and the bloodvessels are limited in number. 

The Clinical Diagnosis of Purulent Salpingitis. 1. Acute 
purulent salpingitis is generally ushered in by marked constitutional 
disturbances. There may be an initial chill; this is followed by 
a rise of temperature and pain referred to the affected tube. In 
nearly every instance there is a similar lesion in the uterus, which 
may mask the more limited affection of the tube. Very often the 



394 SPECIAL DIAGNOSIS 

infection does not stop in the tubes, but is carried on to the ovaries 
and peritoneum, giving rise to additional temperature and pain that 
will wholly mask the clinical manifestations of the affected tube. 
As a rule, the tubes are not involved for from three to five days fol- 
lowing septic infection of the uterus. After complete resolution in 
the uterus and peritoneum the infected tube may fail to resolve, and 
remain distended with pus. This indisposition on the part of the 
tubes to resolve as readily as do other parts of the genital tract is 
explained in part by the lessened power of absorption in the tube, 
but in greater part by the closure of the ends of the tube, thereby 
locking in the pus. 

Repeated exacerbations are the rule. These are brought about 
by sexual excesses, menstrual congestion, and injudicious exercise. 

We seldom find gonorrhoeal infection invading the tubes before 
the second or third week after the initial infection of the cervix. 
As a rule, the general symptoms are not so well marked in gonor- 
rhoea! infection as in other forms of septic infection. 

2. Chronic purulent salpingitis usually begins with an acute attack 
and ends in a pyosalpinx. The general disturbances are in nowise 
proportionate to the extent of the lesion. All symptoms may be 
absent in the presence of an extensive lesion. Menstrual disorders 
in the form of a menorrhagia and dysmenorrhoea are fairly constant 
symptoms. Pain in the region of the tubes and referred to the back 
and thighs, together with digestive disorders, are common com- 
plaints. Sterility is almost sure to result from a bilateral involve- 
ment of the tubes. Martin reports three cases of bilateral pyogenic 
infection of the tubes in which pregnancy followed. 

Palpation of the diseased tubes can usually be accomplished 
without difficulty. When found impossible to clearly outline the 
tubes an ansesthetic should be given. The uterus is first located. 
It is seldom found in the median line, and its range of mobility is 
restricted. The tubes are engaged between the examining fingers, 
and are traced outward from the horns of the uterus or downward 
and backward beside and behind the uterus. They are felt as sen- 
sitive thickened cords varying in consistency, size, position, and 
degree of mobility. The consistency is always firm at the uterine, 
less so at the fimbriated end. The kinks in the tube are felt as 
nodules in its course. Sensitiveness to pressure is directly propor- 
tionate to the acuity of the inflammation. The ovary can be pal- 



DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 395 

pated apart from the tube only in exceptional cases. The position 
of the tube largely depends upon the position of the uterus. In 
retroposition the tubes and ovaries may lie in the pouch of Douglas. 
With the uterus erect and forward, it is scarcely possible for the 
tubes to reach into the pouch of Douglas. There will be no fluctua- 
tion unless the tubes contain a considerable amount of pus. 

The walls of the pyosalpinx are thicker and more resisting to the 
pressure of the contained fluid; hence the tube is rarely so large 
as a hydrosalpinx may become. Furthermore, fluctuation is less 
marked, and there is greater fixity and sensitiveness to pressure. 

The character of the pyosalpinx should be determined when pos- 
sible — that is, whether due to gonorrhoea, puerperal infection, 
tuberculosis, or non-puerperal septic causes. 

The clinical history will often lead to a positive diagnosis, par- 
ticularly in gonorrhoeal and puerperal cases. Gonorrhoea is assumed 
to be the cause when other possible factors are eliminated. 

The presence of a purulent discharge from the urethra and infec- 
tion of the glands of Bartholin will determine the diagnosis of 
gonorrhoeal salpingitis to a moral certainty. Absolute certainty in 
the diagnosis is only obtained by the finding of the gonococcus of 
Neisser in the secretion. 

The Diagnosis of Sactosalpinx. The term sactosalpinx is 
understood to be a Fallopian tube distended with fluid — i. e., blood, 
serum, or pus. Under the generic term sactosalpinx we place 
hsematosalpinx, hydrosalpinx, and pyosalpinx — the end stages of 
catarrhal and purulent salpingitis. The following features are 
characteristic of sactosalpinx: 

The position is at the side of or behind the uterus, extending from 
the horn of the uterus outward or downward. Unless greatly dis- 
tended the tube lies below the normal level, most often close to the 
side of the uterus or immediately behind. 

The consistency is so variable as to render it of little value in 
diagnosis. When fluctuation is present it is of some diagnostic 
significance, but is so often absent that it cannot be relied upon. 

The general contour is significant. We commonly speak of sacto- 
salpinx as being of retort- or sausage-shape. The tube is distorted 
in proportion to the degree of distention. The irregularity in the 
course of the tube can usually be noted in a bimanual examination. 
The tube may be so snugly twisted upon itself as to give to the 



396 



SPECIAL DIAGNOSIS 



examining finger the impression of a round or oval swelling. So 
firmly may the tube adhere to the uterus that the two are felt as a 
single mass. The outline of the tube may be lost in a surrounding 
inflammatory exudate. 

The Diagnosis of the Contents of a Sactosalpinx. Following the 
recognition of a sactosalpinx it is next important to determine the 
contents of the distended tube. This can only be done with cer- 
tainty by an exploratory puncture through the vagina or by an 
exploratory incision. The danger of carrying infection .into the 
tube by the exploring needle is not to be disregarded. Fortunately 
the indications for such a procedure are limited, because whether 
blood, pus, or serum, an operative procedure is indicated. 

Differential Diagnosis. Kelly gives the following differential diag- 
nosis between gonorrhoeal and streptococcic infection of the tubes: 



GONOBBHCEAIi INFECTION. 

1. Slow in its onset, often preceded by in- 

flammation of the external genitals and 
urethra. 

2. Pain localized in one or both ovarian re- 

gions. 

3. No signs of general peritonitis. 

4. Suffers more or less constantly, but may 

have no fever. 

5. Temperature 98.5°-102° F. (38.9° O.). 

6. Pulse accelerated, but of good quality. 

7. Attack lasts from five to fifteen days. 



8. 



10. 



Often presents the appearance of good 
health. 

Gonococci usually found on cover-slip 
preparation from the cervical, urethral, 
or vulvovaginal glandular secretions. 

History of marital gonorrhoea. 



Streptoooocus Infection. 

1. Onset abrupt, following miscarriage, nor- 

mal labor, or topical applications. 

2. Pain more general and severe in the lower 

abdomen. 

3. Usually signs of peritonitis. 

4. Suffers constantly, and usually has a 

septic fever. 

5. Temperature 101°-105° F. (38.3°-40.5° C). 

6. Pulse never feeble and more rapid. 

7. Attack seldom lasts less than a month, and 

may continue three months or more. 

8. Anaemic and weak. 

9. Gonococci not found in the secretions. 



10. Husband sound. 



Appendicitis. 
1. No previous local disturbances. 



2. Chill usually absent. 

3. Pain in right iliac region, sudden onset, 

acute, and not radiating to thighs. 

4. Fever of variable degree. 

5. Muscular rigidity on right side of the 

abdomen. 

6. Inflammatory exudate about appendix 

three to five days after onset of symp- 
toms. 

7. Vaginal examination is rarely painful in 

appendicitis. 



Tubo-ovarian Disease. 

1. Genito- urinary functions previously dis- 

turbed. Usually a history of gonor- 
rhoea! or puerperal infection. 

2. Chill may precede fever. 

3. Gradual onset, pain dull, continuous, and 

radiating. 

4. Fever often entirely absent. 

5. No muscular rigidity unless complicated 

by peritonitis. 

6. Inflammatory exudate in the pelvis felt 

by vaginal examination at the onset of 
the symptoms. 

7. Always painful in tubo-ovarian disease. 



. Krussen says the appendix is involved in 15 per cent, of cases 
of tubo-ovarian disease. 



DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 397 

Martin found appendicitis complicating right-sided salpingitis 
thirteen time^ in 276 cases. Ochsner, in 51 cases of appendicitis, 
found the tube and ovary involved fifteen times. Because of the 
frequency with which appendicitis and salpingitis are associated an 
inflammatory lesion in the right side of the pelvis should suggest a 
possible involvement of both of these structures, and no operation 
is complete on either of these structures without investigating the 
condition of the other. It is possible for a primary appendicitis to 
extend to the rectocsecal connective tissue and on to the pelvic 
connective tissue, giving rise to a secondary parametritis. A similar 
extension may take place along the peritoneum from the caecum 
to the tubes and ovaries. The history of the onset and previous 
complaints are important considerations. Next in point of impor- 
tance is the position of the swelling. Tumefactions in and about 
the tube are intimately connected with the uterus, and can be traced 
to its horn. In appendicitis the swelling is high up in the right iliac 
space, and in enlarging it extends downward into the pelvis in con- 
trast to the swellings of tubo-ovarian diseases, which extend upward 
from the pelvis. In appendicitis it may be possible to palpate the 
tube and ovary apart from the exudate about the appendix. 

A subserous fibroid may be simulated by a pyosalpinx when the 
tube is round, thick-walled, closely adherent to the uterus, and 
surrounded by a firm, sharply-defined exudate. 

The clinical history is important. In pyosalpinx there is a history 
of infection, either puerperal or gonorrhoeal, while in fibroids no 
such history is obtainable. In subserous fibroids the tumor is 
round, sharply circumscribed, not tender to pressure, usually freely 
movable, and unilateral. In pyosalpinx the tumor is more elon- 
gated, less sharply defined, tender to pressure, immovable, and 
often bilateral. In pyosalpinx there are evidences of infection in 
the lower genital tract, while with fibroids such is not the case. 

Parametric exudates are often associated with pyosalpinx, and 
their differentiation may be impossible. The location and general 
contour are the distinguishing features. The onset and general 
clinical manifestations closely simulate each other. 

A pyosalpinx is often bilateral, while a parametric exudate is 
commonly unilateral. The former lies on a higher level at the side 
of or behind the uterus, while the latter lies low in the pelvis in 
direct contact with the vault of the vagina, running from the sides of 



398 SPECIAL DIAGNOSIS 

the uterus directly outward. A pyosalpinx is more sharply circum- 
scribed and is retort- or sausage-shaped. A parametric exudate is 
ill-defined. 

Ovarian and parovarian cysts may closely resemble a hydrosalpinx. 
The diagnosis may be reserved for an exploratory incision. Hydro- 
salpinx is more often bilateral and elongated, and is more limited 
in size. 

New-formations of the tubes are very rare as compared with inflam- 
matory lesions. The presence of ascites associated with tubal 
swellings speaks in favor of malignant new-formations of the 
tubes. 

For the differential diagnosis of salpingitis from tubal pregnancy 
see Chapter XIX. 

III. Tuberculous Salpingitis. 

Etiology. In this country our knowledge of tuberculosis of the 
tubes is largely contributed to by Williams, Penrose, and Edebohls. 

The following statistics are from Veit: 

Wenkel found tuberculosis five times in 575 cases. 

Donhoff found tuberculosis fourteen times in 509 cases. 

Schramm found tuberculosis thirty-four times in 3389 cases. 

Rosthorn found tuberculosis twice in 40 cases. 

Williams found tuberculosis seven times in 91 cases. 

Martin found tuberculosis seventeen times in 620 cases. 

The above constitute a sum total of 79 in 5224 cases, or 1 case 
of tuberculous salpingitis in 66 abdominal sections. 

Kundrat, in 140 abdominal sections for the removal of diseased 
uterine appendages, found tuberculous salpingitis in 4 cases and 
tuberculous endometritis in a single case. 

Williams is undoubtedly correct in his statement that tuberculosis 
often goes unrecognized in a catarrhal or suppurative salpingitis for 
want of microscopic and bacteriologic examinations. 

In two years' time at the Johns Hopkins Hospital the tubes 
removed for inflammatory lesions were found tuberculous in 8 per 
cent. 

The great frequency of genital tuberculosis as a primary lesion in 
the tubes is shown in the statistics of W. Meyer, who reports 67 
cases of primary tuberculosis of the genital tract, of which 57 were 
primary in the tubes. 



DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 399 

We recognize a primary and secondary tuberculous salpingitis. 
Hegar, in his monograph of 1886, speaks of ascending and descend- 
ing infections. The ascending form may be primary or secondary. 
The descending is always secondary. 

The Avenues by Which the Tubercle Bacillus Gains Access to the 
Tubes Are: 1. By the blood current (metastatic invasion), as found 
in secondary involvement of the tubes from a primary focus in 
the lungs in the absence of a tuberculous lesion in the omentum, 
mesenteric glands, peritoneum, or bowel. 

2. By continuity of tissue either from the peritoneum or the 
uterus. In 194 cases of secondary tuberculous salpingitis the peri- 
toneum was primarily involved 110 times (Meyer). When the 
tube is adherent to the bowel at the site of a tuberculous ulcer the 
infection may pass directly from the bowel to the tube without 
involving the peritoneum. Such infections are usually mixed with 
the colon bacillus. 

Emmet described a case in which the tubercle bacillus travelled 
from the uterus through the tube and attacked the peritoneum, 
leaving the tube free. 

3. By way of the lymph current. In this manner tuberculosis 
may be conveyed from the lower genital tract through the broad 
ligaments without passing through the uterus. 

The infection is conveyed to the genital tract by the examining 
fingers, instruments, and coitus. Tuberculosis may be conveyed 
from the husband to the genital organs of the wife, even though 
his sexual organs are normal. 

The infection may travel direct to the tubes without attacking 
the uterus, vagina, or vulva. 

As predisposing causes may be mentioned age, the puerperium, 
and inflammatory lesions of the tubes. Tuberculous salpingitis 
may be found at any period of life from infancy to old age, the 
greatest number occurring from fifteen to thirty years of age. The 
age limits are wider than in any of the other forms of tuberculosis. 
The puerperal uterus, and particularly the placental site, is espe- 
cially susceptible to tuberculous infection. 

Inflammatory lesions of the tubes are likely to have tuberculosis 
engrafted upon them. In this manner we have mixed infections of 
the tubercle bacillus with the gonococcus, staphylococcus, strepto- 
coccus, and colon bacillus. 



400 SPECIAL DIAGNOSIS 

Anatomical Diagnosis. As in other forms of salpingitis we 
recognize an acute and a chronic stage. 

Acute tuberculous salpingitis is very rare. The tube resembles 
the catarrhal form. There is a slight increase in the size of the 
tube together with marked congestion; the mucosa is swollen and 
the secretion increased. The entire wall of the tube is infiltrated 
with small round cells, and in addition to these changes, which are 
those of acute catarrhal salpingitis, giant cells, tubercles, and 
tubercle bacilli are found in the mucosa and, to a lesser degree, 
in the muscularis. The lesion is more pronounced in the fimbriated 
end. The secretion collected in the lumen may be serous, bloody, 
or purulent. 

Fig. 166 




Tuberculosis of the uterus, tubes, and ovaries. The surface of the uterus, tubes, and 
ovaries is covered with miliary tubercles by direct extension from the peritoneum. The 
appendages are matted and enlarged (tuberculous salpingitis and ovaritis). 

From the acute the lesion may merge into a chronic stage closely 
resembling chronic catarrhal or chronic suppurative salpingitis. 
As a rule, there is no acute stage. 

INIiliary tubercles may aggregate to form large tubercles and 
nodules, which in turn may undergo caseous degeneration. The 
lumen of the tube may be filled with caseous material. A tuber- 
culous pyosalpinx may form after the closure of either end of the 
tube. 

There is no way of distinguishing tuberculosis of the tubes either 
in the acute or chronic stage from catarrhal or suppurative salpin- 
gitis except by the discovery of tubercles, giant cells, or tubercle 
bacilli. For this reason tuberculosis in a tube is often over- 
looked. 



DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 401 

Gray or yellowish-gray tubercles; ranging in size from a miliary 
tubercle to a hazelnut, may be seen on the surface of the tube and 
on the peritoneum near by. Adhesions about the tube are usually 
firm and extensive. 

Williams describes a chronic fibroid tuberculous salpingitis in 
which there is a marked fibrous hyperplasia in and between the 

Fig. 167 




Tuberculous tubo-ovarian abscess. The tube and ovary are distended with pus, and 
together form a retort-shaped mass the size of a fetal head. The wall of the cyst is thick 
and covered with dense adhesions. (Specimen removed by Dr. J. Clarence Webster.) 



tubercles. Caseous degeneration is absent. This is a very chronic 
form, and may be regarded as a healing process. 

Calcification of the tuberculous product is described by Klob, 
Penrose, and Rokitansky. 

Clinical Diagnosis. Tuberculous salpingitis may be suspected 
when one or both tubes are found to be enlarged and tender to 
pressure, and the possibility of gonorrhoeal or puerperal infection 

26 



402 SPECIAL DIAGNOSIS 

can be excluded. The presence of tuberculosis elsewhere in the 
body or in the husband, ^nd a tuberculous family history, will speak 
for tuberculosis as the cause of the lesion in the tube. 

In primary tuberculous salpingitis the symptom of greatest 
clinical importance is prolonged and painful menstruation. 

The functions of the bowels and rectum are frequently disturbed. 
Abdominal ascites is found in about 15 per cent, of cases. An 
evening rise of temperature and increase in the pulse rate are 
significant. As a diagnostic test tuberculin may be administered. 

The local findings do not differ at first from those of acute and 
chronic salpingitis. Later nodules may be felt on the surface of the 
tube. There is nothing in the conjoined examination to positively 
identify a tuberculous tube. 

Hegar lays great stress upon the peculiar condition of the middle 
third of the tube, which presents firm, nodular swellings. In the 
absence of peritonitis there are no findings differing materially from 
those of salpingitis in general. The finding of tuberculous peri- 
tonitis naturally suggests tuberculosis of the tubes. An exploratory 
curettage may disclose tubercles in the scrapings. 

In favor of tuberculous salpingitis the following data may be 
given : 

1. The diagnosis of chronic salpingitis. 

2. Tuberculous lesions elsewhere in the body. 

3. Tuberculosis in the husband, particularly when involving the 
sexual organs. 

4. Family history of tuberculosis. 

5. Salpingitis in virgins (90 per cent, are said to be tuberculous). 

6. Tubercle bacilli in the leucorrhoeal discharge or in scrapings 
from the uterus. 

7. Ascites. 

SYPHILIS OF THE FALLOPIAN TUBE. 

Literature on syphilis of the tube is scant, and cases are of rare 
occurrence. Three authentic cases are described by Ballentyne and 
Williams, Donhuff, Bouchard, and Lepine. 

Donhoff discovered the usual changes of catarrhal salpingitis in 
a post-mortem examination of a baby, nine days old, which had 
died of syphilis. 



DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 403 

The case recorded by Ballentyne and Williams was a seven 
months' child. There were numerous small gummata scattered 
throughout the tube wall and obliterating the lumen. 

Bouchard and Lepine reported a case, aged forty years. Death 
was from syphilis. There was a gumma in each tube the size of a 
hazelnut, and the lumina of the tubes were occluded. 

ACTINOMYCOSIS OF THE FALLOPIAN TUBE. 

We know little of actinomycosis of the tubes. Zemann, Stewart, 
Muer, and Granger have contributed all that is now known. In 
the reported cases the lesion was both primary and secondary in 
the tubes. 

PARASITES OF THE FALLOPIAN TUBE. 

Echinococci have been found in the tubes, the infection being 
secondary to that of the abdominal viscera, the pelvic bones, and 
the paraproctal connective tissue. Benoit reported 80 cases found 
in the literature. 

NEW-FORMATIONS OF THE FALLOPIAN TUBES. 

All new-formations of the Fallopian tubes are of rare occurrence. 
Those described are papilloma, polyp, myoma, fibroma, dermoid 
cyst, lipoma, fibromyxoma, cystoma, sarcoma, carcinoma, endothe- 
lioma, syncytioma malignum. 

1. Papilloma arises from the endosalpinx. Sanger was able to 
collect only six cases in the literature. Simple papilloma takes the 
form of a villous or cauliflower growth which may fill and distend 
the tube. The villosities may adhere and lock in cystic spaces. 
The growth is histologically constructed of connective tissue cov- 
ered by a single layer of columnar epithelium, having no disposition 
to invade the connective tissue, as is the case in malignant papilloma. 
Metastasis does not occur. It has been suggested by Doran that 
benign papillary growths are of inflammatory origin. He bases his 
opinion on a certain definite inflammatory reaction seen to accom- 
pany the growth. He believes gonorrhoea to be a potent factor. 

2. Poljrps of the tube are virtually inflammatory lesions. They 
are rarely found. 



404 SPECIAL DIAGNOSIS 

3 and 4. Myoma and fibroma of the tube are not to be mistaken 
for the nodular swellings of salpingitis isthmica nodosa. Five cases 
are reported by Sanger. Bland Sutton reported one the size of an 
orange. V. Recklinghausen reported an adenomyoma of the tube 
arising from the duct of Miiller. 

5. Dermoid cysts of the tube are described by Pozzi and Richie. 

6. Lipomata are not of such unusual occurrence in the tube. 
They are usually located between the two layers of the mesosalpinx, 
and have been known to attain the size of a hen's Qgg. 







Fibromyxoma fimbriarum tubre cystosum. U, uterus; Td, right tube; Od, right ovary; 
Ts, left ovary; Its, left infundibulum of the tube; Os, left ovary; Txl, pedunculated 
tumor; Tnll, pedunculated tumor; Tj, secondarj' pedunculated tumor; Ov, calcareous 
body resembling an ovary ; A', cyst containing dark-yellow fluid ; Y, gelatinous tissue 
without cavities; I, blood cysts with blood detritus; II, blood cyst with fresh blood; 
III, soft myxomatous tumor; IV, soft myxomatous tumor. (Martin.) 

7. Fibromyxoma cystoma of the fimbrse was described by 
Sanger (Fig. 168). There were three tumors connected by fimbriae 
to a normal tube. They consisted of fibrous and myxomatous 
tissue. 

8. Sarcoma of the tube has a papillary structure that cannot be 
distinguished from benign papilloma or carcinoma by the naked 
eye. But five cases are recorded. 

9. Carcinoma of the Fallopian tube may be primary or sec- 
ondary. Orthmann was the first to describe primary carcinoma 



DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 405 

of the tube. Like other new-formations of the tube, carcinoma 
assumes a papillary form, and in its histological structure is not 
unlike papillary adenoma of the ovary and malignant adenoma 
of the uterus. Secondary carcinoma of the tube resembles the 
primary growth, and is usually an extension from a similar growth 
in the uterus. One-third of the primary carcinomata of the ovary 
extend to the tube. It has been repeatedly observed that inflam- 
matory lesions of the tubes serve as forerunners of carcinoma. 

Le Count^ says: ''It is especially concerning tumors of the 
Fallopian tube that confusion has arisen; there has been quite a 
general failure to recognize that a diffuse hyperplastic inflammation 
is possible — a process that is strictly analogous to the polypous 
hyperplasia of other mucous surfaces — and that in certain typical 
examples it is as distinct from tumor growth as gastritis proliferans 
is from carcinoma of the stomach." He believes it is fully demon- 
strated that there exists an imperceptible transition of hyperplastic 
processes of the tubal mucosa into those of true tumor growth, and 
that these may terminate in the production of benign tumors and 
then into a malignant new-formation. 

We find carcinoma of the tubes occurring about the time of the 
menopause — a time when inflammatory lesions are less frequent. 

Sanger-Barth observed a direct malignant degeneration of the 
tubal mucosa. Doran and Fearne observed a malignant transfor- 
mation in a benign papilloma. 

Carcinoma of the Fallopian tube is commonly unilateral. Zange- 
meister reported three cases of primary carcinoma of the tube, all 
of which were bilateral. All six tubes presented the external appear- 
ance of sactosalpinx. The tube walls were thin. Within the tubes 
were papillary growths which under the microscope resembled 
adenocarcinoma of the uterus. Zangemeister found 51 cases in 
literature. According to Sanger-Barth, it usually arises from the 
middle and outer portions of the tube. 

In conformity with many authors we will recognize two micro- 
scopic forms — the papillary and the alveolar. 

The papillary form consists of numerous papillae composed of 
connective tissue and covered by columnar epithelium. 

^ The Genesis of Carcinoma of the Fallopian Tube in Hyperplastic Salpingitis, with a 
Report of a Case and a Table of Twenty-one Reported Cases. Johns Hopkins Bulletin, 
March, 1901. 



406 SPECIAL DIAGNOSIS 

Alveolar carcinoma of the tube shows a greater proliferation of 
the epithelium and the grouping of these epithelial elements into 
nests. 

CYSTIC NEW-FORMATIONS OF THE FALLOPIAN TUBES. 

Hydatids of Morgagni are transparent cysts containing a clear, 
watery fluid. They are found on the peritoneal covering of the 
tube and broad ligament, either isolated or arranged in groups. 
The fimbrise of the tube may distend with a similar fluid and present 
the appearance of cysts of Morgagni. 

Cysts as large as walnuts have been found in the mucosa of the 
tube, and are inclusions of the mucous folds. 

Cysts of equal size are found in the musculature. These arise 
from the ducts of Gartner. 

The following classification is from Sanger: 

1. Serous cysts, lying beneath the serous covering of the tube 
and varying in size to a child's head. 

2. Lymphangiectasis. 

a. As small cysts on the tube and ligament. 

h. Winding canals or cysts located under or within the peri- 
toneum of the tube and broad ligament. 

c. Lymphangiectatic cysts, large and isolated, located in the 
subserosa of the tube and in the mesosalpinx. 

3. Hydatids of Morgagni, which are to be regarded as physio- 
logical, and are located in the fimbriae. 



CHAPTEE XXXI. 

THE DIAGNOSIS OF DISEASES OF THE OVARY. 

Normal Anatomy of the Ovary. 
Methods of Examination. 
Anomalies in Development. 
Changes in Position. 

Descensus Ovarii. 

Hernia Ovarii. 
Hypertrophy of the Ovary. 
Atrophy of the Ovary. 
Parasites and Foreign Bodies. 
Circulatory Disturbances. 

Hsematoma. 
Inflammation of the Ovary (Ovaritis). 

Cystic Degeneration. 

Abscess. 

Clinical Diagnosis of Ovaritis. 

Differential Diagnosis of Ovaritis. 
Infectious Granulomata. 

Tuberculosis. 

Syphilis. 

Actinomycosis. 

Leprosy. 
New-formations. 

NORMAL ANATOMY OF THE OVARY. 

The ovaries are two in number, lying behind the broad ligaments 
on a level with the brim of the pelvis, midway between the horn of 
the uterus and the psoas muscle. The ovary is oval in shape and 
about the size of an almond. The average measurements, as given 
by Farre, are: longitudinal diameter, one-third of an inch; trans- 
verse diameter, three-quarters of an inch; perpendicular diameter, 
three-eighths of an inch. The anterior border (hilum) is flat, and 

(407) 



408 SPECIAL DIAGNOSIS 

is attached to the broad Ugament; the posterior border is convex and 
free. The ovary Ues in a shallow concavity formed by the posterior 
layer of the broad ligament. This fossa of the broad ligament is a 
remnant of the peritoneal pouch in which the ovary of the rat and 
other mammalians is enclosed. Such a fossa was observed in a 
case operated by J. Clarence Webster. 

The ligaments of the ovary are two in number — the ovarian 
ligament and the infundibulo-pelvic ligament. In addition to these 
ligaments the ovary is attached at its hilum or anterior border to 
the posterior layer of the broad ligament. The injundibulo-pelvic 
ligament connects the outer end of the Fallopian tube to the side 
wall of the pelvis, and may be regarded as that portion of the upper 
border of the broad ligament not occupied by the Fallopian tube. 
It is about 2 cm. in length. 

The ovarian ligament extends from the horn of the uterus to the 
inner end of the ovary, and is about 3 c.cm. long. 

THE HISTOLOGY OF THE OVARY. 

The ovary is covered with a layer of nucleated columnar cells 
continuous at the hilum with the peritoneal endothelium. At the 
point of transition is a white, glistening line called the ''white line 
of Farre." The epithelium covering the ovary is called the "germ 
epithelium of Waldeyer," and beneath it is a fibrous layer known 
as the tunica albuginea. 

The framework of the ovary is of connective tissue, and is divided 
into cortical and medullary portions, the former lying external to 
the latter. The Graafian follicles are scattered throughout the 
ovary. Nerves, bloodvessels, lymphatics, and muscular fibres are 
also found in the connective tissue. The medullary portion is 
more vascular than the cortex. 

The Graafian follicles number 40,000 to 70,000 in the infant 
ovary. They vary in size from one one-hundredth to one-thirtieth 
of an inch in diameter. The younger and smaller follicles occupy 
the medullary portion, and as they grow larger they are found to 
occupy the cortical portion. A Graafian follicle consists of: 

1. A tunica fibrosa and membrana propria. 

2. The membrana granulosa and discus proligerus. 

3. The liquor folliculi. 



DIAGNOSIS OF DISEASES OF THE OVARY 



409 



4. The ovum surrounded by the discus proligerus and composed 
of: 
a. Zona pellucida, a homogeneous external membrane 
h. Yolk protoplasm. 

c. Germinal vesicle. 

d. Germinal spot. 



Fig. 169 



Mmhriated 

extremity. 




Fimbria ovarica. 

Uterine appendages, seen from behind. (Henle.) 



METHODS OF EXAMINATION OF THE OVARY. 

The bladder and rectum should be empty, and all restricting 
clothing removed from the waist. An anaesthetic is not always 
required, but is helpful in all cases and indispensable in many. 
The patient is placed in the lithotomy position. The abdomino- 
vaginal method is usually chosen. If the vagina is short, resisting, 
or sensitive to pressure, or if the hymen is intact, it will be advis- 
able to make a rectoabdominal examination. When the ovary lies 
behind the uterus it may be better palpated through the rectum. 

As a matter of routine, it is advisable to first locate the uterus, 
then follow from the horn of the uterus along the course of the tube 
to the ovary. The right ovary is best detected by the finger of the 
right hand in the vagina and the left ovary by the finger of the 
left hand. It is not, as a rule, necessary to change hands; either 



410 



SPECIAL DIAGNOSIS 



the right or the left hand will suffice in most cases for the exam- 
ination of both ovaries. 

In difficult cases Ulmann recommends filling the rectum with a 
colpeurynter to force the ovary upward and forward within easier 



reach of the examinino^ fingfer. 



Fig. 170 




Section of the ovary: 1, outer covering; 1', attached border; 2, central stroma; 3, 
peripheral stroma; 4, bloodvessels; 5, Graafian follicles in their earliest stage; 6, 7, 8, 
more advanced follicles ; 9, an almost mature follicle ; 9', follicle from which the ovum 
has escaped; 10, corpus luteum. (After Schron.) 



ANOMALIES IN THE DEVELOPMENT OF THE OVARY. 

1. Absence of one or both ovaries may occur as a congenital 
defect, or the entire ovarian tissue may be completely lost through 
atrophic changes and new-formations. When both ovaries are 
absent the uterus and tubes are either altogether wanting or poorly 
developed. Menstruation and childbearing are impossible. In a 
case reported by Quain there was vicarious menstruation from the 
nose. Two of Martin's cases were sexual perverts : one a nympho- 
maniac, the other a prostitute. Martin collected twenty-two cases 
of congenital absence of one ovary. In one of his cases the uterus 
was normal, but the right tube and ovary were absent. In another 
the uterus and vagina were rudimentary, and the left tube and 
ovary absent. In nine of the twenty-two cases there was a uterus 
unicornis. The vagina and vulva are seldom influenced by the- 
absence of a single ovary, and mav be well formed where both 
ovaries are absent. 



DIAGNOSIS OF DISEASES OF THE OVABY 411 

Torsion of the tube or adhesions surrounding the tube and ovary 
may shut off the blood supply and cause complete atrophy of the 
ovary. 

The diagnosis of the absence of one or both ovaries can only be 
made by inspection after the abdomen is opened. 

2. One or Both Ovaries May be Congenitally Small. This 
condition may be primary or secondary. Martin reports thirty-six 
cases of rudimentary ovaries; none menstruated, and only seven 
experienced the molimina. Twelve of the thirty-six cases had 
a rudimentary vagina, and in every case the uterus was under 
size. 

Rudimentary ovaries have been recognized by a conjoined exam- 
ination, though this is exceptional. 

3. Supernumerary ovaries are accounted for either as an ac- 
quired segmentation of the ovary or as a congenital defect. In 500 
cases supernumerary ovaries were found eighteen times by von 
Wenkel. Sanger reported one that measured 1 cm. by 0.04 cm. 
As a rule, they are much smaller. Pregnancy following the 
removal of both ovaries is explained by the presence of a super- 
numerary ovary. 

A true supernumerary ovary is a rare finding, but an accessory 
ovary constricted off by adhesions is a comparatively frequent 
lesion. These accessory ovaries may be connected with the ovary 
by a pedicle or be completely isolated. Small pedunculated bodies 
are frequently seen near the ovaries; these are detached tubes of 
the parovarium, small myomata of the ovarian ligament, or stalked 
corpora fibrosa. 

The clinical significance of superrlumerary ovaries is in the 
continuation of the menstrual and childbearing functions after the 
removal of both ovaries. 

The diagnosis can only be made by direct inspection. 

4. One or Both Ovaries May be Congenitally Large. This 
anomaly is occasionally found associated with precocious develop- 
ment of the sexual organs. Hypertrophy of the ovary is more often 
an acquired lesion. It is physiological during pregnancy and is 
commonly associated with uterine fibroids. 

It must be remembered that the normal ovary varies in size 
within wide limits. 



412 SPECIAL DIAGNOSIS 

CHANGES IN THE POSITION OF THE OVARY. 

The normal position of the ovary is at the level of the brim of 
the pelvis midway between the horn of the uterus and the psoas 
muscle. There is a limited physiological range of motion influenced 
by changes in the position of the uterus, the filling and emptying 
of the bladder and rectum, the respiratory movements, and changes 
in the attitude of the patient. During pregnancy the ovaries are 
elevated into the abdominal cavity. 

Pathological causes of misplaced ovaries are: 

1. Displacements of the uterus and tubes. 

2. Inflammatory lesions of the ovaries, increasing the weight of 
the ovaries and causing them to fall to a lower level, or adhesions 
about the ovary drawing the organ out of place. 

3. New-growths about the ovaries, crowding them out of place. 

4. Increase in size and weight of the ovaries from abscesses, 
hsematomata, and tumor formations, causing them to prolapse. 

Decensus Ovarii. Classification (Sanger). 1. Descensus lateralis, 
in which the ovary descends no farther than the upper border of 
the sacral ligament. 

2. Descensus posticus, in which the ovary descends below the 
upper border of the uterosacral fold. 

The causes of descensus ovarii are : 

1. Increase in the weight of the ovary by: 

a. Hypertrophy and hyperplasia. 
h. Congestion. 

c. Hsematoma or abscess. 

d. New-formations. 

2. Relaxation of the supporting ligaments of the ovary. 

3. Retropositions and prolapsus uteri. 

4. Pelvic adhesions pulling upon the ovaries. 

5. Pelvic and abdominal tumors pushing the ovaries downward. 

6. Severe falls. 

In 4000 cases Martin found the ovary descended in 564, and of 
this number a single ovary was prolapsed eighty-six times. The 
greatest number was found between the ages of twenty-five and 
thirty. They are rarely seen after fifty years of age. 

A. prolapsed ovary rarely remains normal. The dependent posi- 
tion interferes with the return circulation, and this leads to a chronic 



DIAGNOSIS OF DISEASES OF THE OVARY 413 

hyperplasia of the ovary (chronic- ovaritis). In the 564 cases re- 
ported by Martin chronic ovaritis was found 401 times. In 15 
there was cystic degeneration of the ovary, and in 154 cases there 
was periovaritis with fixation from adhesions. 

Diagnosis. The diagnosis is based altogether upon the physical 
findings. The symptoms are wholly unreliable in identifying the 
lesion. Excessive symptoms occurred only twenty-six times in the 
564 cases of Martin. Painful menstruation, dyspareunia, and pain 
in defecation are those commonly present, though they are by no 
means constant. How much parametritis and other complicating 
lesions have • to do with these symptoms cannot be determined. 
Sterility does not necessarily follow. It is difficult if not impossible 
to demonstrate that the reflex symptoms, such as headache and 
dyspepsia, are dependent upon diseases of the ovary. 

The displaced ovary is recognized by its size, form, consistency, 
and sensitiveness to pressure. An anaesthetic is always of advan- 
tage and may be indispensable. A rectoabdominal examination is 
often more satisfactory than a vaginoabdominal. 

Not only must the position of the ovary be located, but it is 
necessary that the cause of the displacement be ascertained. 

Hernia of the Ovary. Hernia of the ovary may be congenital or 
acquired. Congenital hernia of the ovary is commonly bilateral, 
and acquired hernia unilateral. Inguinal hernia is by far the most 
frequent form, though the ovary may descend through the crural 
ring, navel, ischiadic and obturator foramina. In pseudoher- 
maphrodites the ovary, having descended through the inguinal canal, 
is likely to be mistaken for the testicle. Menciere reports a single 
case in which the uterus, together with the ovaries and tubes, was 
found in the hernial sac. So long as the ovary is not incarcerated 
and the circulation remains undisturbed no symptoms will arise. 
When from compression or torsion the return circulation is impeded 
the ovary becomes swollen from venous stasis, and may finally 
become gangrenous. The symptoms inaugurated by this condition 
are pain, vomiting, and collapse. 

The diagnosis rests exclusively upon the finding of the ovary. 
When the ovary and tube alone are found in the hernial sac and 
the abdominal wall is not thick and sensitive, there should be 
little difficulty in establishing a diagnosis. The ovary is recog- 
nized by its size, form, consistency, and sensitiveness to pressure, 



414 SPECIAL DIAGNOSIS 

and in a conjoined examination the Fallopian tube is found to 
connect the displaced ovary with the uterus. The percussion note 
is dull in contrast to the tympanitic note of the bowel. The absence 
of the corresponding ovary in the pelvis is evidence in favor of 
hernia of the ovary. 

A hydrocele of the canal of Nuck is distinguished from hernia 
of the ovary by the cystic, fluctuating character of the swelling 
and by the presence of the ovary in the pelvis. 

It is difficult to distinguish strangulation and gangrene of the 
ovary from a strangulated intestinal hernia. Tympany on percus- 
sion is elicited in either case. Finding the ovary in the pelvis will 
exclude the possibility of hernia of the ovary. Not infrequently 
an exploratory incision is required to establish the diagnosis. 

When the hernia is congenital or when acquired before the time 
of puberty the condition may go unrecognized until puberty, when 
the ovary becomes enlarged and tender during the menstrual periods. 

HYPERTROPHY OF THE OVARY. 

The size of the ovary varies within wide limits, and hence it is 
not always possible to distinguish between a normal ovary and one 
that is hypertrophied. Hypertrophy of the ovary frequently com- 
plicates uterine fibroids. Such an ovary measuring four inches in 
length was removed by Webster together with a fibrocystic tumor 
of the uterus which weighed eighty-seven pounds. 

In true hypertrophy there is an increase in the amount of ovarian 
tissue. This condition is not to be confounded with hyperplasia 
of the connective-tissue stroma, the result of passive congestion 
and inflammation. There are no characteristic clinical signs of 
hypertrophy of the ovary. Early puberty, unusual sexual vigor, 
and a late menopause are the ascribed manifestations. 

ATROPHY OF THE OVARY. 

The physiological atrophy of the ovary in the climacteric may 
occur some time before the menstrual periods altogether cease, or 
may be delayed many years. Atrophy of the ovary usually pre- 
cedes the menopause by a year or more, but is seldom complete for 
several years after the menopause, 



DIAGNOSIS OF DISEASES OF THE OVARY 415 

A pathological atrophy of the 'ovary results frora interference 
with the nutrition of the organ and from direct and continuous 
pressure upon the ovary by tumor formations and inflammatory 
exudates. Inflammatory adhesions may contract about the ovary 
and tube, limiting the blood supply and bringing on atrophy. 
Swellings of the tubes, uterus, and ovaries may cause pressure 
atrophy. Atrophy of the ovary may follow the infectious and 
contagious diseases, syphilis, diabetes, the primary and secondary 
anaemias, myxoedema, morbus Basedowii, tabes dorsalis, acro- 
megaly, and poisoning by arsenic and phosphorus. 

Varicosities of the veins of the mesovarium have been reported 
by Palmer Dudley as being responsible for atrophy of the ovary. 
Martin, in his report of forty cases, takes the position that the 
majority of women with atrophied ovaries suffer from pulmonary 
tuberculosis. 

The menstrual functions become less active as the atrophy of the 
ovaries progresses. The individual often increases in weight. 
Nervous disturbances are frequently complained of. These are 
pain and throbbing in the head, flashes of heat and cold, insomnia, 
irritability of temper, and despondency. A positive diagnosis is 
reserved until direct inspection of the ovaries can be made. Atrophy 
together with cystic degeneration frequently explains the early 
occurrence of the menopause. 

PARASITES AND FOREIGN BODIES OF THE OVARY. 

The echinococcus has been identified in the ovary by Freund, 
Schultze, Schatz, Orth, and Pfannenstiel. The diagnosis can only 
be made by the finding of the organism in the ovary. 

Foreign bodies have rarely been found in the ovary. Calcareous 
concretions and needles have been discovered. 

CIRCULATORY DISTURBANCES IN THE OVARY. 

Etiology. There is a physiological hypersemia of the ovary 
during menstruation, coition, and pregnancy. 

The ovaries share in a general pelvic congestion, hence all embar- 
rassments to the general circulation from diseases of the heart, 
lungs, kidney, and livery from abdominal tumors, collectiong of 



416 SPECIAL DIAGNOSIS 

fluid in the abdomen, and constipation will cause passive congestion 
of the ovaries. 

In certain hemorrhagic diseases, such as scorbutus and purpura, 
there are hemorrhages into the substance of the ovaries. Hyper- 
semia of the ovary is a constant accompaniment to all the inflam- 
matory lesions in the pelvis. The more acute the lesion the greater 
the hypersemia. As remarked in the section on Descensus Ovarii, 
the ovary is congested. 

Hsematoma of the ovary is often of obscure origin". It is possible 
for hemorrhages to occur in the ovary as the result of any of the 
above-named causes for hypersemia. As an underlying factor, we 
may have degenerative changes in the bloodvessels of the ovary. 
Such collections of blood are usuallv found in the follicles; hemor- 
rhages into the interstitial spaces are less common. Virchow and 
Olshausen each report a case complicating scorbutus. Torsion of 
the tube and ovarian ligament may cause hemorrhages into the 
stroma and follicles of the ovary. 

^Martin reported 109 cases in which blood collections in the 
ovaries varied in size from that of a bean to a man's fist. Of this 
number 25 were observed between the ages of eighteen and fifty- 
two; 22 were not married; the right ovary was affected forty-seven 
times, the left fifty-five times, and both ovaries thirty-two times. 
In all but 8 cases there was more or less peritonitis, and 4 of the 8 
had uterine fibroids, 1 chlorosis, 2 endometritis and metritis, and 
the eighth practised masturbation. In 26 of the 109 cases a trau- 
matic cause could be traced in the history, such as the passing of 
the uterine sound, the wearing of pessaries, and the replacing of the 
uterus. Hsematoma is an unusual finding in an otherwise perfectly 
normal ovary. Any of the new-formations and inflammatory lesions 
may accompany hsematoma. 

Anatomical Diagnosis. In hypersemia of the ovary we find a 
slight increase in size in all diameters and a more livid color. Fol- 
lowing a long-standing hypersemia there is an increase of the con- 
nective tissue. The tunica albuginea is thickened, and the follicles, 
failing to rupture through the thick and resisting tissue, lead to 
follicular degeneration of the ovary. 

Haematoma Ovarii. Hemorrhages into the substance of the ovary 
are found in one or more of three places — follicles, corpus luteum, 
or connective spaces, 



DIAGNOSIS OF DISEASES OF THE OVARY 



417 



1. Hemorrhages into the follicles may distend them to the size of a 
man's fist. More than a single folhcle may be involved! The 
stretched walls of the follicles with their contained blood appear of 
a bluish tint. The contained blood may or may not be coagulated 
and is dark red or grayish-brown. The inner surface of the follicles 
is smooth, though occasionally made uneven by coagulated blood 
adhering to the surface. Fatty degeneration of the epithelium 
lends a yellowish tint to the inner surface. The contained blood 
may be wholly absorbed or converted into fibrin, which by contract- 
ing may obhterate the follicles. Occasionally the follicle bursts, 



Fig. 171 




Hsematoma of the corpus luteum. The ovary is greatly hypertrophied, and at the distal 
end is a single protruding blood cyst the size of an English walnut, formed from a corpus 
luteum. 

and the blood escapes into the peritoneal cavity. The escaped 
blood has been known to set up a peritonitis, and cases are recorded 
where the hemorrhage was fatal. Infection of the blood may give 
rise to abscess formation in the ovary. 

2. Hemorrhages into the corpus luteum are identified by the cor- 
rugated lining membrane of lutean cells or by the granular appear- 
ance. Such bodies are single, and are located in the periphery of 
the ovary. Hsematoma of the corpus luteum has been known to 
attain the size of a child's head. 

3. Hemorrhage into the connective-tissue spaces is less common. 
Such hemorrhages are often multiple, and are seldom of large size, 

^7 



418 SPECIAL DIAGNOSIS 

Multiple punctate hemorrhages may be distributed through the 
stroma and add materially to the size of the ovary. 

The blood is found in various stages of preservation. In fol- 
licular haematoma the epithelium lining the blood cyst may be well 
preserved, assuming a variety of shapes from cylindrical to flat- 
tened. Several layers may be found. In the larger hsematomata 
there may be but a single layer of flat epithelium, and even this 
may partially or wholly disappear through pressure atrophy. Blood 
extravasations and congested bloodvessels may be seen in the 
tunica propria. 

In the hsematoma of the corpus luteum the wall is more congested 
and thicker than in the preceding variety. On the inner surface 
of the cyst there is a deposit of fibrin, in the meshes of which 
are disintegrated blood and small round cells. Beneath this are 
the lutean cells, varying in number, size, and form according to the 
age and size of the hiematoma. External to the lutean cells is 
the tunica externa, composed of fibrous tissue. 

Clinical Diagnosis. There may be no clinical manifestations. 
The ovary is usually tender to pressure. Pain in the ovary may 
radiate to the back and thighs. The pain is at its height during 
the period of premenstrual congestion, and abates when a free flow 
is established. 

It has been said that when pelvic congestion is present and a 
throbbing pain develops in the ovary, with no elevation of tem- 
perature, it is to be inferred that a hsematoma has developed in 
the ovary. A diagnosis can only be made on exploration of the 
ovary. 

In a bimanual examination the ovary is invariably found enlarged, 
though it is seldom larger than a walnut. The consistency is tense 
and elastic. 

Although sharply circumscribed, the ovary is usually irregular 
in outline. It is found on a lower level than normal, often lying 
low beside or behind the uterus. 

It is difficult and often impossible to differentiate hypersemia, 
hsematoma, and inflammation of the ovary. The pain and tender- 
ness may be equally intense, and there may be no distinction in the 
physical findings. In inflammation the symptoms are usually of 
longer standing and more pronounced. The history of the onset 
should be considered, 



DIAGNOSIS OF DISEASES OF THE OVARY 41 9 

INFLAMMATION OF THE OVARY (OOPHORITIS, OVARITIS). 

For practical clinical purposes inflammation of the ovary will be 
classified as acute and chronic. 

I. Acute Ovaritis. Acute inflammation of the ovary is due to 
direct invasion of the ovary by bacteria or to the influence of their 
toxic products. Certain inorganic poisons (phosphorus, arsenic) 
act in a similar manner. 

All the infectious diseases may be complicated by ovaritis, in- 
cluding the exanthemata, typhoid fever, cholera, pneumonia, 
influenza, dysentery, wound infections, gonorrhoea, and tuber- 
culosis. 

The micro-organisms found in the ovary under such conditions 
are the staphylococci, streptococci, pneumococci, gonococci, typhoid 
bacilli, and actinomyces. 

In all the above-named causes of ovaritis the same general ana- 
tomical changes follow, there being no essential difference in the 
anatomy of the various etiological forms. 

Pfannenstiel considers acute ovaritis under the heads of septic 
and gonorrhoeal. 

1. Acute septic ovaritis is a complication of puerperal sepsis, but 
a similar lesion may arise from the non-puerperal septic agencies 
above named. 

The ovary is uniformly enlarged and reddened, and the stroma 
becomes infiltrated with a serous exudate and small round cells. 
The follicular epithelium degenerates, the ovum dies and is 
absorbed, and the liquor foUiculi becomes turbid. Suppuration 
may follow, leading to the formation of abscesses in the corpus 
luteum, follicles, and interstitial spaces. 

Death may follow, but resolution is the rule, and this is possible 
either by complete absorption of the exudate leaving the ovary in 
a normal condition, or by atrophy of the connective tissue, with its 
subsequent contraction. 

2. Acute gonorrhoeal ovaritis is rarely primary, and is almost 
invariably secondary to salpingitis. In exceptional cases the infec- 
tion is conveyed from the cervix through the lymphatics of the 
broad ligaments to the hilum of the ovary. 

Wertheim has succeeded in demonstrating the gonococcus in the 
Ovary^ . 



420 



SPECIAL DIAGNOSIS 



II. Chronic ovaritis is a clinical term designating a long-stand- 
ing lesion of the ovary characterized by hyperplasia of the stroma 
and secondary atrophy of the parenchyma. 

Chronic ovaritis may be the terminal stage of an acute infection 
of the ovary. Any condition causing prolonged congestion of the 
ovary will result in chronic ovaritis, such, for example, as sexual 
excesses, menstrual congestion, subinvolution, malpositions of the 
uterus, habitual constipation, incompetency of the cardiovascular 



Fig. 172 




Chronic ovaritis with follicular degeneration. 



system, pelvic and abdominal tumors, and disorders of the organs 
of digestion. 

Cystic Degeneration of the Ovaries. It may now be fairly 
stated that the profession in general has come to regard cystic 
degeneration of the ovaries in a less serious light than was first 
presented, but yet accords the lesion a rightful place among the 
morbid conditions of the ovary. 

I have made microscopic and clinical studies of 180 cases in 
which one or both ovaries were removed or resected for follicular 



DIAGNOSIS OF DISEASES OF THE OVARY 



421 



degeneration. Of the 180 cases, 160 were operated by Dr. Web- 
ster, 20 by myself; only 39 of these cases were uncomplicated. 
In 141 of the cases the ovaries were operated in connection with 
other lesions. My observations have extended over a period of 
twenty-two months. From the clinical records I have tabulated 
the clinical signs which appear to be directly referable to the ovary. 
In this I have met with difficulty because of the frequent presence 
of associated lesions which often mask those ordinarily ascribed 
to the ovary. In many instances it has not been possible to say 



Fig. 173 




Follicular degeneration of the ovary. The ovary contains one large follicular cyst and 
numerous small ones. The stroma is increased and prevents the rupture of the cysts. 
Near the outer border of the ovary is an old corpus luteum. The cysts contain a clear 
serous fluid. 



that the cystic ovaries have contributed to the symptom-complex 
because of the presence of more serious lesions. 

After the removal of all existing lesions, and relief from all symp- 
toms obtained, it has not always been possible to say to what extent 
the resection or removal of the ovaries contributed to the recovery. 
For example, cystic degeneration of the ovaries associated with 
salpingitis and retroversion of the uterus with adhesions might 
give rise to backache, sterihty, and dysmenorrhoea, and contribute 
to general nervous phenomena, but it is manifestly impossible to 
determine to what extent the ovaries contributed to the suffering 



422 SPECIAL DIAGNOSIS 

and disability. However, it may be expected that anatomical and 
clinical studies of a large number of these cases would yield some 
valuable suggestions, and especially so when compared with similar 
studies of uncomplicated cases. 

In reviewing the opinions of the observers who have written upon 
the subject, including Virchow, Gebhard, Abel, Klob, Zieglerj 
Ruge, Pfannenstiel, Amann, Martin, and Frakin, I find it to be 
the consensus of opinion that follicular degeneration is the result 
of chronic ovaritis; that these follicles do not arise from cell inclu- 
sions, as stated by Nagel, but are the direct result of passive con- 
gestion and hyperplasia of the stroma. 

As a suggestion of the pathological nature of follicular cysts, 
Martin observes that they are not confined to the outer zone of the 
ovary, as is the case with ripened follicles, but, on the contrary, 
are distributed throughout the stroma. This he regards as of 
greater significance than the number and size of the follicles. Mar- 
tin does not attempt to fix the normal limits in size for a follicle, 
but says they are manifestly pathological when they approach the 
ovary in size, whether they contain ova or not. 

Ziegler described a follicular cyst the size of a man's head, and 
Martin reports one which weighed seventeen pounds. 

In the 180 cases of cystic degeneration of the ovaries in which 
complete or partial removal of one or both ovaries was done the 
following anatomical conditions were noted: the cysts varied in 
size from a pea to an English walnut, and in number from one 
to a score or more. 

Reference to the diagrams in Fig. 174 shows that these cysts, 
as Martin has pointed out, are not confined to the periphery of the 
ovary, as is the case with ripened follicles, but are distributed 
throughout the stroma and may almost replace the stroma. 

On microscopic examination of these ovaries I have been aston- 
ished to note the scarcity of normal follicles which contained ova. 
In a few sections none were to be found, and in nearly all they were 
fewer in number than would appear to be normal. The explana- 
tion probably lies in the atresia brought about by the addition of 
new connective tissue to the stroma and its subsequent contraction. 
In a small percentage of cases fresh corpora lutea were found, 
showing the ovary capable of functionating. In all of them corpora 
albicantes were abundant. 



DIAGNOSIS OF DISEASES OF THE OVARY 



423 



Hyaline degeneration is a prominent feature in nearly all sec- 
tions. The walls of bloodvessels, corpora albicantes, stroma, and 
tunica albuginea all possess more or less of a hyaline deposit. This 
has been marked in the ovaries of young individuals. Congestion 
of the bloodvessels, while not constant, was a notable feature in 
almost all cases. Round-cell infiltration of the stroma was fre- 
quently observed. 

Fig. m 







Follicular degeneration of the ovary. The diagrams illustrate the distribution of the 
follicular cysts throughout the stroma of the ovary. Almost the entire ovary is replaced 
by the cysts. 



Gland-like structures, the remains of Gartner's ducts, were occa- 
sionally found in the hilus of the ovary. In the follicles, not exceed- 
ing a pea in size, the membrana granulosa and ova were usually 
found, and, when present, the ova were never in a healthy state. 
In the larger cysts I have carefully searched for lutean cells in the 
walls, but have repeatedly failed, and in many there were traces 
of membrana granulosa and theca. Cysts the size of a walnut were 
undoubtedly follicular, though a larger number were from corpora 
lutea. 



424 SPECIAL DIAGNOSIS 

A review of the clinical history of these 180 cases includes the 
records of the pathological findings at the time the operation was 
made, with a view of determining to what extent these morbid 
changes in the ovary contributed to the suffering of the patient, 
and for the purpose of determining, if possible, the clinical impor- 
tance of the lesion. 

Of the 180 cases, 39 were uncomplicated by pelvic lesions other 
than follicular degeneration of the ovaries. A careful clinical study 
of these uncomplicated cases should afford some definite conclu- 
sions. In the remaining 141 cases in which there were complicating 
pelvic lesions, it has been possible, to a certain extent, to note the 
role played by the cystic ovaries, but this was only attempted after 
a careful analysis of the uncomplicated cases. 

In the 39 uncomplicated cases general pelvic pains were com- 
plained of in 16; pain in the region of the left ovary in 11; pain in 
the region of the right ovary in 10, and pain in the back in 19 cases. 
It was a rule, to which there were a number of exceptions, that the 
pain was referred to the affected ovary. When both ovaries were in- 
volved the pain was likely to be distributed throughout the pelvis, 
and when one or both ovaries were cystic and lay behind the uterus 
there was usually backache. In each case pelvic pain was com- 
plained of. Tenderness was almost always elicited by pressure upon 
the affected ovaries. In 18 of the 39 cases there was dysmenorrhoea, 
and in the most of these cases the pain preceded the appearance 
of the menstrual flow and continued throughout the period. 

In 34 cases the flow was normal or decreased in amount; in 5 
cases there was menorrhagia; 6 of the cases were sterile; 6 were 
married, and the remaining 27 had borne from one to nine children. 
In three cases it is recorded that the patient was hysterical, and in 
11 cases general nervous disturbances were complained of. Head- 
ache was present in 15 cases. 

In reviewing the histories of the 141 complicated cases I have 
satisfied myself in many instances that the cystic ovaries contributed 
in the above manner to the discomfort of the individual. 

Varicose ovarian veins in the broad ligaments are doubtless a 
more common factor in the causation of cystic degeneration of the 
ovaries than would be inferred from these statistics. Doubtless 
they were not always recorded when found, and the Trendelenburg 
position would empty the veins and make them less prominent. 



DIAGNOSIS OF DISEASES OF THE OVARY 425 

The passive congestion in the ovaries as the direct result of vari- 
cosities in the ovarian veins would lead in time to hydrops of the 
follicles, and the hyperplasia of the stroma would hinder the rupture 
of the enlarged follicles. 

The average of the cases when operated was thirty-two years. 
The youngest was nineteen years, and the oldest forty-eight years. 
The greatest number were operated between thirty and forty years 
of age, but there was an almost equal number between twenty and 
thirty years. The usual infectious diseases of childhood were 
experienced in 65 per cent, of the 180 cases; and there was a history 
of puerperal, postabortive, or gonorrhoeal infection in 63 per cent. 
The average duration of the symptoms was seven years. These 
observations have led me to the following conclusions: 

1. Cystic degeneration of the ovaries is almost invariably the 
result of chronic ovaritis, which in turn is caused by infection 
or passive congestion of the ovary. It is, therefore, a morbid 
lesion. 

2. One or more ripened follicles in the ovary are not to be mis- 
taken for follicular degeneration. 

3. Symptoms referable to cystic degeneration of the ovaries are 
pelvic pain and tenderness, dysmenorrhoea, sterility, and general 
nervous phenomena. Of these symptoms, pain is of constant occur- 
rence, but is not constant in character or location. Too much 
stress is not to be laid upon the complaint of pain and tenderness, 
for undoubtedly the explanation frequently lies in the presence of 
associated lesions or in an instability of the general nervous 
system. 

4. Cystic degeneration of the ovaries doubtless contributes to 
a general nervous state, but in my judgment this can only be due 
to the local discomfort. I doubt if there can exist a general dis- 
turbance of the nervous system referable to the ovaries without 
local discomfort. Therefore, in the absence of local disorders, the 
general nervous phenomena should not call for surgical intervention 
or for any consideration of the ovaries. 

Abscess of the Ovary. We may speak of acute and chronic 
abscesses of the ovary. 

1. Acute abscess of the ovary is seldom recognized in a clinical 
examination. Such abscesses commonly arise in the course of acute 
general septic infections with a speedy fatal termination. Hence 



426 SPECIAL DIAGNOSIS 

it is the rule that acute abscesses of the ovary are usually discovered 
in a postmortem examination. 

2. Chronic Abscess of the Ovary. Menge, in 33 cases of ovarian 
abscesses, found the gonococcus in 9, the colon bacillus in 4, the 
streptococcus in 1, saprophytic anaerobic micro-organisms in 1, 
and in 18 the pus was found sterile. ]\Iartin found the pus sterile 
in 20 out of 55 cases. 

Anatomical Diagnosis. As in hsematoma, so in abscess of the 
ovary, there are three localities in which they may develop — the 
interstitial spaces, the follicles, and the corpus luteum. 

Interstitial abscesses are found in all portions of the ovary. They 
are usually multiple and irregular in outline. The wall of the 
abscess is composed of connective tissue infiltrated with small 
round cells. 

Follicular abscesses usually present a smooth wall of connective 
tissue. They may be single or multiple, and may attain the size of 
a man's head. 

Corpus luteum abscesses are recognized by the corrugated inner 
lining of the cyst wall. The abscess lies superficially and is usually 
single. The blood coagulum in the centre of a corpus luteum is a 
favorable nidus for pyogenic micro-organisms. This, with the 
superficial position of the corpus luteum and its intimate connection 
with an infected tube, makes infection easily possible. 

Tubo-ovarian abscess, by which is understood a pyosalpinx directly 
communicating with an ovarian abscess, may be primary or sec- 
ondary. A primary tubo-ovarian abscess begins as a pyosalpinx 
and an ovarian abscess, which later communicate and form one 
continuous abscess cavity. A secondary tubo-ovarian abscess arises 
from a secondary infection of a primary tubo-ovarian cyst. 

In 110 cases of ovarian abscesses Martin found a tubo-ovarian 
abscess in 18. 

Clinical Diagnosis of Ovaritis. The clinical picture is a 
variable one. The ovary is seldom involved alone, hence the 
clinical picture of ovaritis is rarely observed independent of com- 
plicating inflammatory lesions. 

Acute ovaritis causes a rise of temperature and increase in the 
pulse rate. There is exquisite tenderness on pressure over the 
ovary, so much so that an anaesthetic is required in palpating it. 
For practical purposes a diagnosis of acute inflammation of the 



DIAGNOSIS OF DISEASES OF THE OVA BY 427 

adnexa is sufficient. When the acute stage of the inflammation has 
subsided the ovary can be outUned by a bimanual examination. 

In chronic ovaritis there is no elevation in temperature. Pain 
in the region of the affected ovary radiating to the groin and thigh 
is the most constant symptom. Occasionally the pain recurs at 
regular intervals between the menstrual periods ("miittleschmertz"). 
The explanation of this phenomenon is the ripening and bursting 
of the follicles through the resisting stroma and tunica albuginea. 
Individuals show a marked difference in their susceptibility to 
pain. 

Chronic ovaritis may exist to a marked degree without causing 
pain, while on the other hand a very slight involvement of 
the ovary may cause intense suffering. The pain is aggravated 
during the period of premenstrual and menstrual congestion. The 
pain of chronic ovaritis is often but the expression of a general 
nerve storm, and it is difficult, indeed, to determine just how much 
the lesion in the ovary has to do with the pain. 

In the early stage of chronic ovaritis the menses are increased, 
but, as the true ovarian tissue gives place to connective tissue, the 
menses become more and more scant. Sterility is a common com- 
plaint, and is the immediate result of such complicating lesions as 
salpingitis and endometritis more often than of ovaritis. When 
the cause of sterility rests in the ovary, the explanation lies in the 
destruction of the ova and in the failure of the follicles to rupture 
through the thickened stroma, tunica albuginea, and surrounding 
adhesions. 

When suppuration of an ovary follows upon ovaritis the symp- 
toms are all aggravated. In acute abscess of the ovary the 
symptoms are all masked by the complicating peritonitis, metritis, 
and salpingitis. 

Increase in the pulse rate and elevation of temperature are to be 
expected in acute abscesses, but are often wanting in the chronic 
stage. 

In determining the cause of the infection it is important to con- 
sider the clinical history, as a possible childbirth, abortion, or 
gonorrhoeal infection may play a part. 

Physical examination of the pelvic viscera and of the leucorrhoeal 
discharge may reveal a gonorrhoeal or tuberculous infection of 
other portions of the genital tract. 



428 SPECIAL DIAGNOSIS 

The diagnosis is made in part by a consideration of the above 
symptoms, but an absokite diagnosis cannot be made without a 
physical examination, and is often reserved until an exploratory 
incision offers further light. 

Tenderness and pain may be complained of in the presence of a 
perfectly normal ovary, and chronic ovaritis may exist without 
causing pain or tenderness on pressure. 

Direct palpation of the ovary in a bimanual examination under 
anaesthesia is indispensable in making a diagnosis. The slight 
increase in size and consistency of the diseased ovary, together 
with evidence of infection elsewhere in the genital tract, will best 
suggest the diagnosis. 

The diagnosis cannot be based upon the increase in size in the 
absence of pain and tenderness. Hypertrophy and cystic degen- 
eration of the ovary will cause a similar increase in the size. 

Abscess of the ovary cannot be diagnosed from constitutional 
symptoms. Chills, fever, rapid pulse, and pain may all be absent 
in the presence of an ovarian abscess. 

The diagnosis is based upon the finding of a rounded swelling 
beside or behind the uterus, and not immediately connected with it. 
The tube may be traced from the swelling to the horn of the uterus. 
The ovary is tender to pressure, and is always restricted in its 
movements by adhesions. Fluctuation is not often elicited. 

It is sometimes possible to judge of the liability of the abscess 
to rupture by the degree of tension associated with the pain. At 
such a time the temperature and pulse are usually elevated, and 
there are increasing pressure symptoms referred to the rectum 
and bladder, and along the sacral nerves to the thighs and back. 

On rupture of the abscess the temperature may drop and the 
pain cease. If the abscess has ruptured through the vagina, rec- 
tum, bladder, or abdominal wall there will be an escape of pus, 
which is usually fetid and mixed with blood. If the abscess rup- 
tures into the peritoneal cavity and the pus is confined by adhesions, 
there will be a moderation in the temperature and pain. If no 
adhesions protect the peritoneum there will rapidly follow symp- 
toms of general suppurative peritonitis. Return of the abscess 
in the ovary is of common occurrence. Fistulse and chronic sup- 
puration are possible results which demand the removal of the sac 
long after a spontaneous rupture. 



DIAGNOSIS OF DISEASES OF THE OVARY 429 

Differential Diagnosis. Congestion of the ovary may be mis- 
taken for an inflammation. The history of the development of the 
lesion and the duration and intensity of the disturbance are the 
guides to a diagnosis. No sharp line can be drawn between these 
lesions, even by anatomical studies of removed ovaries, and hence 
it is impossible to clearly define the two conditions. 

Salpingitis is often associated with ovaritis, and the two may be 
inseparably connected, so that it is impossible to distinguish the 
ovary from the tube in a bimanual examination. Adhesions bind- 
ing the tube and ovary may unite them into a single rounded or 
oblong tumor mass. 

In general it may be said that inflammatory swellings of the 
tube are elongated, retort-shaped, and immediately connected with 
the horn of the uterus, while inflammatory swellings of the ovary 
are round and not so intimately connected with the uterus. 

Parametric exudates lie at a lower level in the pelvis than does 
an ovarian abscess. The swelling is more diffuse and is absolutely 
immovable. Furthermore, a parametric exudate is intimately 
connected with the uterus, and is more often unilateral than are 
ovarian abscesses. An ovarian abscess is slower in its development 
and slower in being absorbed than is a parametric exudate. 

Perityphlitis is usually not difficult to distinguish from inflamma- 
tory lesions of the ovary. The higher location on the right side and 
the accompanying disturbances of the digestive organs will usually 
serve to exclude the ovary. The diagnosis will be made with cer- 
tainty by outlining the ovary apart from the perityphlitic exudate. 

New-growths of the ovary, including ovarian cysts, are less tender 
to pressure, the pain is rarely so fixed, and the outline of the tumor 
is often quite irregular. Finally, their tendency to grow to a large 
size will serve as points of distinction. 

SIMPLE CYSTS OF THE OVARY. 

Among simple cysts of the ovary will be included those cystic 
formations occupying an intermediate position between the cystic 
inflammatory lesions and the cystic new-formations. 

1. Follicular Cysts. See page 420. 

2. Corpus luteum cysts, as the name implies, arise from the corpus 
luteum, and hence are single and are located on the periphery of the 



430 SPECIAL DIAGNOSIS 

ovary. As compared with follicular cysts, they are thick-walled. 
In size they vary from a bean to a man's head. 

The wall of the cyst presents the characteristic yellow corrugated 
appearance of the luteum cell layer, and external to this is the pale, 
fibrous envelope. The contents of the cyst is commonly a clear, 

Fig. 175 




Corpus luteum cyst. Numerous small follicular cysts are seen in the substance of the 
ovary. At the periphery of the ovary is a thin- walled cyst double the size of the ovary, 
and originating in a corpus luteum. (Specimen removed by Dr. J. Clarence Webster.) 

serous fluid; this is occasionally mixed with blood and degenerated 
cells. 

3. Tubo-ovarian Cysts. These have been previously referred to. 

Rathorn gives the following groups in explanation of the origin 
of tubo-ovarian cysts; 



DIAGNOSIS OF DISEASES OF THE OVARY 431 

Group I. 

1. Cases in which a pyosalpinx becomes adherent to the wall 
of an ovarian abscess, with subsequent communication established 
between them. Later the formed elements of the pus are absorbed, 
leaving a serous fluid. 

2. Adhesions of the pavilion of the tube to the wall of the sup- 
purating ovarian cyst, with subsequent development of hydrosalpinx 
and perforation of the cyst into the tube. 

3. x^dhesions of a hydrosalpinx to a papillomatous cyst, with 
subsequent perforation of the intervening wall by papillary growths. 

Group II. 

1. Cases in which a hydrosalpinx becomes adherent to the wall 
of a follicular cyst, with subsequent perforation of the septum. 

2. Cases in which the fimbrise of a previously diseased tube 
become caught in the opening of a ruptured follicle at the moment 
of rupture and become adherent to the wall of the follicle. 

Anatomical Diagnosis. A tubo-ovarian cyst may distend to 
the size of a child's head. The general form is that of a retort. 
The wall is thin and transparent. Occasionally there are adhesions 
about the cyst. No evident ovarian tissue may be found. 

The interior of the cyst resembles a hydrosalpinx on one side and 
a follicular or corpus luteum cyst on the other. There is but a 
single cavity. The point of union of the cyst and tube is sharply 
defined. The tubal portion is lined with ciliated epithelium and 
the ovarian portion either with a fibrous or granular surface layer or 
with a low type of epithelium. The contents is clear serum, rarely 
blood-stained. 

The clinical diagnosis cannot be made from hydrosalpinx. The 
diagnosis is only made by a careful examination of the specimen 
after its removal. 

INFECTIOUS GRANULOMATA OF THE OVARY. 

Of the infectious granulomata we find in the ovary tuberculosis, 
syphilis, actinomycosis, and leprosy. 

Tuberculosis. Etiology. Tuberculosis of the ovary is a compara- 
tively rare lesion. One hundred and eighty-four cases were reported 
by von Guillemain, Wolf, Martin, and Bulius. In Wolfs cases 42 
were bilateral, 48 unilateral. No case of primary tuberculosis of the 



432 SPECIAL DIAGNOSIS 

ovary has been reported. However, the ovary may be the primary 
seat of attack in the genital organs when the initial lesion lies else- 
where in the body; but this is rare. As a rule, the primary lesions 
lie within the tube or in the peritoneal cavity. In 410 cases of 
tuberculosis of the genital tract the ovary was involved in 84. 
Bland Sutton says: ''An ovarian abscess unassociated with salpin- 
gitis is in nearly all cases tuberculous. Records of primary ovarian 
tuberculosis require careful and critical consideration before accept- 
ance." The invasion of the ovary is usually by direct continuity 
from the peritoneum and tubes to the ovary; more rarely by the 
lymph and blood streams. 

Anatomical Diagnosis. jNIartin classifies the tuberculous lesions 
of the ovary as follows; 

1. Tuberculous periovaritis, in which the tubercles are dis- 
tributed over part or all of the surface of the ovary as miliary or 
larger tubercles. It is a direct invasion of the ovary from the tube 
and peritoneum. 

2. Tuberculous ovaritis, in which miliary tubercles are dis- 
tributed throughout the ovarian tissue. More often distinct cheesy 
masses, or tuberculous abscesses, are found to occupy the interior 
of the ovary. Cheesy masses rarely reach the size of a hazelnut, 
while tuberculous abscesses may attain the size of a child's head. 

Tuberculous tubo-ovarian abscesses have been reported by 
Williams, Menge, and Mosler. The author adds another case. 
As a rule, the lesion is bilateral; occasionally ascites accompanies 
tuberculosis of the ovary, and is the result of tuberculous peritonitis. 

Microscopic Diagnosis. In tuberculous periovaritis there are 
typical tubercles on the surface and in the neighborhood of the 
ovary. The surface epithelium is intact, save where the tubercles 
are located. The superficial tubercles may directly invade the 
underlying stroma. This is accomplished by way of the lymph or 
blood stream. In a case of Frank the lutean cell layer was covered 
with miliary tubercles. No primary invasion of the follicles has 
been observed. The usual point of invasion is the connective-tissue 
stroma. Cheesy masses are generally sharply defined from the sur- 
rounding stroma and are single or multiple. Tuberculous abscesses 
of the ovary are usually lined with irregular cheesy walls and granu- 
lation tissue beset with miliary tubercles. The surrounding con- 
nective tissue contains giant cells and tubercles, and commonly 



DIAGNOSIS OF DISEASES OF THE OVARY 433 

undergoes hyaline degeneration. The tubercles may be found in 
the purulent contents of the abscess or in the abscess wall. Sec- 
ondary infection with pyogenic organisms has been demonstrated. 
Dermoid cysts have been known to contain tubercle bacilli. 

Clinical Diagnosis. Since primary tuberculosis of the ovary, has 
not been recognized, it has not been possible to say just what the 
symptom-complex would be. We find the usual general and local 
evidences of chronic ovaritis. The tuberculous character is inferred 
from the family and personal history and the finding of tuberculous 
lesions elsewhere in the body, particularly in the tubes and peri- 
toneum. 

Syphilis of the Ovary. Syphilitic lesions are rarely found in the 
ovary. Orth reported the finding of a gumma. Richet also 
describes hyperplastic and atrophic changes in the ovary due to 
syphilis. Lecorche found in a postmortem case hyperplastic changes 
in the ovaries with calcareous nodules in the cortex. In this case 
death was caused by general syphilitic infection. Tuberculosis and 
syphilis have been observed to coexist in the ovary (Baumgarten). 

The diagnosis cannot be determined because of the lack of oppor- 
tunities for observation. In syphilitic infection with accompanying 
lesions of the ovary, if the regular antisyphilitic treatment results 
in a cure of the ovarian lesion, the diagnosis is established. 

Actinomycosis of the Ovary. This is a very rare condition, and 
is a secondary invasion from the vagina or intestine. Abscesses, 
single or multiple, are found in the ovary. They are usually inter- 
stitial. There is nothing to characterize their true nature from 
other abscesses save the organism in the pus. The diagnosis can- 
not be made without a microscopic examination of the purulent 
contents. 

Leprosy of the Ovary. Babes found inflammatory lesions in 
the ovary together with the specific organism which he ascribes 
to leprosy. The presence of leprosy elsewhere in the body with a 
chronic ovaritis of no assignable origin affords a probable diagnosis. 

NEW-FORMATIONS OF THE OVARIES. 

Etiology. Ovarian tumors were found in 1.4 per cent, of 36,158 
cases in Martin's chnic. The following table from Stander shows 
the relative frequency of various tumors of the ovaries : 

28 



434 SPECIAL DIAGNOSIS 

Cystadenoma 205 = 69.49 per cent. 

Carcinoma 40 = 13.56 " " 

Embryoma 26 = 8.81 " " 

Sarcoma 20 = 6.78 " " 

Fibroma 4 = 1.36 " " 

Referring to the age at which ovarian tumors appear, we find 
Doran reporting a case of sarcoma of the ovary in infancy, and 
Homans operating upon a tumor of the ovary at eighty-two years 
of age. The following is a table prepared by Olshausen in which 
are given the number of tumors found and the respective ages of 
the patients: 

61 under ....... 10 years. 

490 between 20 and 29 " 

499 " 30 " 39 " 

372 " 40 " 49 " 

342 at 50 " over. 

It will be seen from the above table that tumors of the ovary 
occur with about equal frequency between the ages of twenty and 
fifty years. 

The social state has no influence upon the development of ovarian 
tumors; they occur with about equal frequency in the single and 
married. They may be the cause of sterility, but it is not likely 
that sterility predisposes to their development. 

While two or more members of the same family have been known 
to be afflicted with ovarian tumors, it is not believed that heredity 
plays a role in the development of these neoplasms. In 1000 cases 
of Spencer's, 8.2 per cent, were bilateral, while Olshausen gives 
13.7 per cent, in 322 cases. 

Classification. The old classification of tumors of the ovary 
into cystic and solid tumors was of the greatest service when the 
operative treatment was limited to the tapping of fluid. At the 
present time, when tumors of the ovary are removed en masse, such 
a classification does not meet the requirements. 

Tumors of the ovary are classified as benign and malignant. 
Waldeyer classifies them according to their histology and histogene- 
sis into epithelial (parenchymatous) and connective-tissue (inter- 
stitial) forms. Either of these forms is benign or malignant, and 
may be cystic or solid. A combination of the parenchymatous 
and interstitial forms are the so-called mixed tumors. 

Epithelial new-formations of the ovary take their origin from 
the germinal epithelium of the follicles, rarely from Miiller's duct. 



DIAGNOSIS OF DISEASES OF THE OVARY 



435 



From these sources are derived the benign and malignant, the 
cystic and the papillary tumors. 



Fig. 176 




Multilocular cyst of the ovary. The ovary is converted into two large cysts with serous 
contents. A fresh corpus luteum is seen on the surface of the smaller cyst. The tube is 
normal. (Specimen removed by Dr, J. Clarence Webster.) 



436 SPECIAL DIAGNOSIS 

An adenoma, pure and simple, is rarely seen. More often it is a 
combination of adenoma and fibroma (adenofibroma). When the 
gland spaces widen we speak of cystadenoma. These large cystic 
spaces result from the distention of glands by the retained secretions 
(non-proliferating cysts) and from proliferation of the epithelial 
and connective-tissue elements in addition to the distention of the 
glands. 

The secretion of these cysts differs. Pfannenstiel introduced 
the terms cystadenoma pseudomucosum when the contents is of a 
mucous character, and cystadenoma serosum when the contents is 
serous fluid. 

The purely granular type may be found, or papillae may spring 
from the surface of the cyst. It is possible to have a papillary cyst 
on one side and a glandular cyst on the other. One may be intra- 
peritoneal, the other extraperitoneal. They are rarely of equal 
size. 

Intraperitoneal cysts are pedunculated and are usually freely 
movable, while extraperitoneal cysts seldom have a pedicle and are 
fixed. Such extraperitoneal cysts are usually completely enfolded 
in the broad ligament, but are sometimes partly within the free 
peritoneal cavity. Cysts of very large dimensions may have but a 
single cavity, but, as a rule, one or more smaller cysts lie within 
the parent cyst and are known as daughter cysts. These smaller 
ones may give an irregular surface and a variable consistency to the 
original cyst. By rupture of the daughter cysts into the parent 
cyst a multilocular may be converted into a unilocular cyst. There 
are usually some remnants of the walls of the daughter cysts left 
in the form of ridges and bands. 

As the cyst enlarges the wall becomes thinner, more transparent, 
and glistening. In the wall of the cyst many bloodvessels are seen 
to take an irregular course; the veins are larger and more numer- 
ous than the arteries. 

Villous projections are frequently seen growing from the inner 
surface of the cyst wall. The villosities vary in size and extent 
and form wart-like excrescences, sometimes long and slender, like 
a feather. The framework of the papillae is of connective tissue in 
which bloodvessels course. Covering the stroma are one or more 
layers of columnar epithelium, showing many irregular foldings and 
reduplications which might be mistaken for malignant proliferation. 



DIAGNOSIS OF DISEASES OF THE OVARY 



437 



The connective-tissue growth does not keep pace with that of the 
epitheHum. Similar papillary growths appear on the external sur- 
face of the cyst. These arise either from the surface epithelium or 
from within the cyst, and subsequently penetrate the wall. 

Microscopic examination of the cyst wall shows a vascular frame- 
work of connective tissue with more or less round-cell infiltration. 

Fig. 177 




Multilocular proliferating cyst of the ovary. There are numerous small cysts and one 
large, thin-walled one. Such a cyst is not self-limited in its growth, and may attain an 
enormous size. (Specimen removed by Dr. J. Clarence Webster.) 



In the smaller cysts true ovarian tissue is sometimes present. On 
the outer surface of the cyst wall germinal epithelium is commonly 
seen, though it may be partially or wholly lost. The inner surface 
is lined with a secreting epithelium of cylindrical form and often 
ciliated. This epithelium remains intact, whatever the size and 



438 



SPECIAL DIAGNOSIS 



age of the cyst. To the unaided eye the inner surface appears not 
unUke the mucous membrane of the stomach. 

When nutrition is insufficient certain retrogressive changes fol- 
low. Occasionally the cyst contents are absorbed, and the cyst wall 
contracts, thereby diminishing its size. 

Calcareous degeneration of the cyst wall may be partial, or, as in 
the case of Leopold, complete. 

Fig. 178 




Cross-section of a multilocular pseudomucinous cyst of the ovary. The parent cyst contains 
a number of daughter cysts of similar structure and containing a mucinous substance. 



Other secondary changes in the cyst, to be described later, are 
hemorrhage into the cyst, torsion of the pedicle, rupture of the wall, 
infection of the contents, and malignant degeneration. 

Rupture of a cyst may be followed by closure of the rent and 
refilling of the cyst, or the rent may remain open and the contents 
be discharged continuously into the peritoneal cavity. In excep- 
tional cases the cyst shrinks and disappears after rupture. 



DIAGNOSIS OF DISEASES OF THE OVAEY 439 

If the contents of the cyst is serous the escaped fluid will be 
absorbed, but if mucus escapes into the peritoneal cavity absorption 
is slow and a pseudomyxomatous peritonitis may possibly develop. 
Small hemorrhages into the cyst wall are of common occurrence, 
and have no clinical significance. Hemorrhagic effusions into the 
cyst wall predispose to rupture, and life may be endangered 
by the rupture of large bloodvessels. 

Fig. 179 



4 









z 

^ <5 '4,, 






,1 






'^\ ^ 



Pseudomucinous ovarian eyst. The cyst is lined within by a single layer of high columnar 
epithelium with an oval nucleus near the base of the cell. The cyst wall is composed of con- 
nective tissue containing gland-Uke structures. 

When torsion of the pedicle shuts off the blood supply and there 
are no adhesions through which nourishment is carried to the cyst, 
atrophy or gangrene of the cyst will follow. It is possible for adhe- 
sions to convey sufiicient blood to fully nourish the cyst and even 
permit it to increase in size. 

a. Cystadenoma pseudomucinosum (Hammarstan) contains a 
mucinous secretion, clear and transparent, or turbid from cell debris 
and blood. A large amount of blood may give a chocolate color to 



440 SPECIAL DIAGNOSIS 

the fluid. White, flocculent particles float in the fluid. These 
consist of mucin, cell debris, cholesterin, blood corpuscles, and fat 
droplets. The epithelium lining the cyst is a single layer of high, 
slender, cylindrical cells, with clear, transparent bodies and oval 
nuclei near the base. 

The pseudomucinous cysts are by far the most common of the 
large ovarian cysts. They are commonly adenomatous, rarely 

Fig. 180 




(/oyi^JLi^ — ^ 



Multilocular papillomatous cyst of the ovary. An irregular multilocular cyst of the ovary 
has on its surface a large irregular area of benign papillomatous growths. These warty 
growths tend to spread over the surface of the cyst and over all peritoneal surfaces in the 
abdomen. The extension of the growth is by continuity of tissue, not by metastasis in the 
benign form. 

papillomatous, though a limited number of papillary growths is 
often found projecting from the cyst wall. 

According to Martin more than two-thirds are unilateral and 
only about 7 per cent, are extraperitoneal. The largest recorded 
cyst weighed 245 pounds. 

h. Cystadenoma serosum contains a clear serous fluid of a pale- 
green color; it is rarely turbid from admixture with cell debris, or 
chocolate color from admixture with blood. 



DIAGNOSIS OF DISEASES OF THE OVARY 



441 



These cysts rarely attain the enormous size of the mucinous 
variety. They are frequently papillary, and as such are often 
bilateral. 

Papillary growths may not only cover the inner surface of the 
cyst and penetrate to the outer, but may spread by continuity of 

Fig. 181 




Cross-section of a multilocular papillomatous cyst of the ovary. Growing from the outer 
and inner surfaces of the cyst are papillary growths. The contents of the cyst is serous 
fluid. Microscopic examination of a papillomatous growth, including the cyst wall, shows 
the growth to be benign. 

II 

tissue to the peritoneum, where by mechanical irritation ascitic 
fluid is secreted. 

A papillomatous growth of the ovary without cystic formation is 
an unusual condition. The secreting epithelium consists of low, 
cylindrical-shaped cells, with round nuclei near the centre. (See 
Plate LV.) 

CARCINOMA OF THE OVARY. 



Our knowledge of primary carcinoma of the ovary is very limited. 
The majority of carcinomata are secondary. 



442 SPECIAL DIAGNOSIS 

Classification. Waldeyer gives the following classification: 

1. Simple (carcinoma simplex). 

2. Medullary (carcinoma medullaris). 

3. Scirrhus (carcinoma scirrhosum). 

Many secondary forms may be added, such as atrophic, colloid, 
melanotic, sarcomatous, gelatinous, and microcystic. 

The frequency of carcinoma of the ovary is stated by Martin as 
13.6 per cent, of his cases of ovarian tumors. 

About three-fourths of them are unilateral. Bilateral invasion 
of the ovary is always associated with involvement of the peri- 
toneum and other structures, and hence is inoperable. 

As pointed out by Sutton, it is a curious rule that organs which 
are frequently the seat of primary carcinoma are rarely the seat 
of secondary deposits, and vice versa. This is exemplified in the 
ovary. In primary carcinoma of the mammary gland the ovaries 
were invaded five times in 85 cases (Coupland). Sutton found the 
ovaries invaded six times in 52 cases of inoperable carcinoma of 
the uterus, and three times in 29 cases of inoperable carcinoma of 
the breasts. 

Olshausen says an important feature in the clinical history of 
ovarian cancer is the fact that it often occurs at an early age, 
and may even develop during childhood. The following table was 
constructed by Olshausen: 

8 to 19 years ...... 19 patients. 

20 " 29 " 17 " 

30 " 39 " 
40 " 49 " 
50 years and above 

Anatomical Diagnosis. In solid carcinomatous tumors of the 
ovary the general form of the ovary is maintained. The surface is 
uneven and studded with tubercles, nodules, or papillary growths. 
Rarelv is the surface smooth. It is unusual to find normal ovarian 
tissue, yet the occurrence of pregnancy in bilateral involvement of 
the ovaries shows that some follicles remain healthy. In the large 
tumors cystic spaces are invariably present. Malignant degenera- 
tion of ovarian cysts is of more common occurrence. In all forms 
of carcinoma of the ovary the carcinoma cells maintain their cylin- 
drical shape and form cancer nests or gland-like structures not 
dissimilar to those found in carcinoma of the Fallopian tube. 

Papillary growths which have perforated a cyst wall are prone to 



DIAGNOSIS OF DISEASES OF THE OVARY 443 

undergo malignant degeneration and to rapidly spread to the peri- 
toneum. As pointed out by Abel, where cancerous degeneration is 
suspected, the cyst should not be tapped before removal for fear of 
contaminating the peritoneum and setting up metastatic growths. 

Squamous-cell carcinoma of the ovary has been observed in 
dermoid cysts. 

Metastasis does not occur so widely in carcinoma of the ovary as 
in carcinoma of the uterus. The most likely points of invasion are 
the peritoneum, omentum, and retroperitoneal glands. 

DERMOID CYSTS OF THE OVARY. 

Dermoid cysts, as the name suggests, are cystic tumors containing 
skin structures. 

In Martin's classification we find simple dermoid cysts, compli- 
cated dermoid cysts, cystic teratoma, and solid teratoma. 

A simple dermoid cyst is a sac lined with a dermal membrane. 
A complicated dermoid cyst is lined with skin and contains hetero- 
geneous structures, such as glands, bone, and teeth. A cystic tera- 
toma contains formed organs, such as brain, mammary glands, 
thyroid glands, etc. A solid teratoma contains no large cysts and is 
composed of structures similar to those found in ordinary teratoma. 

From Bandler we quote: ''The pronephros, the Wolffian body, 
and the Wolffian duct, through their position in the mesoderm, 
their connection between ectoderm and coelome, their relation to 
the normal development of the ovary, their subsequent position at 
the hilus of the ovary, and the extension of the tubules into the 
vascular layer and their growth through the ovary even up to the 
surface, and from the fact that their remnants furnish the ciliated 
growths of the broad ligament and form the cystadenomata of the 
ovary, are capable of carrying with them mesodermal and ecto- 
dermal cells up to or into the ovary, and of forming mesodermal 
and ectodermal products and structures lined with ciliated epithe- 
lium. . . . Cysts of the testicles lined with ciliated epithelium 
originate from remnants of the Wolffian body tubules. Therefore, 
the mesodermal tumors, the mixed tumors, and the dermata of 
the ovary and testicles originate in this same manner. . . . 
If ectodermal cells are displaced to any extent so that their 
presence is manifested by cutis-like tissue, hair, sebaceous glands, 



444 SPECIAL DIAGNOSIS 

etc., we speak of dermoid cysts. If the displaced cells are, so 
to speak, located in one part of the organ concerned, and if they 
grow equally, and if the skin cells, as in the normal skin and 
the sebaceous glands, excrete their products, a cystic dermoid must 
result. Since the contents found in dermoid cysts are excreted 
by the so-called 'derm' of the cyst, they must lie, when secreted, 
between the derm and the enveloping tissue composing the 
organ or tissue in which the dermoids grow. The larger the 
amount of this secretion the greater is the pressure on the secondary 
tissue. If the mass of the secreted matter reaches a fair amount, 
and if it causes a tissue growth in its periphery, and if it compresses 
the overlapping organ so that it is stretched or flattened, we then 
have a cystic dermoid whose wall consists of so-called 'skin,' of 
granulation tissue, and of the tissue of the enveloping organ. The 
original group of displaced cells is found then as a prominence only 
in one part of the so-called cyst wall, and it is this part which grows 
gradually for years, and in which are found the hair, the sebaceous 
glands, and other elements found in the inner surface of a dermoid 
cyst. The greater the amount of substance secreted, and the greater 
the amount and number of the products found by the displaced 
ectodermal cells, the larger the cyst. 

''If, on the other hand, the displaced cells are not grouped in 
one part of the organ concerned, and if, at the same time, the ecto- 
dermal cells are not present in too great number, there develops a 
tumor in which the various tissue forms grow into each other. 
Since these ectodermal cells do not form in such a case a so-called 
'derm,' and since they cannot bring about a formation of a cyst 
through their excretion as above described, a tumor form results 
which is relatively solid and which seems to be of an entirely dif- 
ferent structure — a so-called 'teratoma.' 

"In ovarian dermoids and teratomata ectoderm is present in 
large amount; therefore, teeth are frequently found, and their 
occurrence is in contrast with their rarity in the testicle. The 
origin of teeth is to be explained by the united presence of ectoderm 
and mesoderm in these tumors." 

Anatomical Diagnosis. A dermoid cyst may occupy part or 
all of the ovary, and as many as five distinct and separate dermoids 
have been found in the same ovary. They are commonly intra- 
peritoneal and are rarely found between the layers of the broad 



DIAGNOSIS OF DISEASES OF THE OVARY 



445 



ligament. Both skin and mucous membrane are found in the cysts. 
The amount of skin found varies greatly. It may completely line 
a large cyst or may be confined to a single daughter cyst. 

Foreign structures found in dermoids are hair, teeth, nails, horns, 
sebaceous and sudoriferous glands, mammae, bone, unstriped muscle 
fibre, brain and nerve tissue. 

The hair may be rolled into a ball and lie free in the cyst cavity, 
or tufts of hair may spring from the cyst wall. The hair has been 



Fig. 182 




Multilocular dermoid cyst. 

known to be five feet in length (Munde). The color varies from 
blond to black, and does not usually correspond to the color of the 
patient's hair. It is known to turn gray in old age, and at this 
time the cyst may become bald. 

The teeth may be embedded in bone resembling a rudimentary 
jaw or in the fibrous wall of the cyst. More than 400 teeth have 
been found in a single dermoid cyst of the ovary. They represent 
teeth of every description and develop on the same plan as teeth in 
the normal situation. They are not scattered irregularly through 



446 



SPECIAL DIAGNOSIS 



the cyst unless present in large numbers, but are grouped together. 
Nails and horns project from the surface of the cyst. Sebaceous 
and sweat-glands raay be numerous, and may form retention cysts. 
Bone in shapeless masses or in plates is occasionally found. Nerve 
matter has been detected in dermoid cysts. 



Fig. 183 







A conaposite drawing of the microscopic appearance of a dermoid: a, an epithelial pearl 
in section; h, glandular tissue; c, developing hairs; d, developing teeth; e, sweat-gland in 
section. 



Mammje, in the form of a nipple attached to rounded projections 
of tissue containing sebaceous glands and more or less fat, are occa- 
sionally found, and completely formed glandular structures have 
been discovered. Dr. Desiderius reported a case in which the 
gland secreted milk and colostrum. 

Dermoid cysts of the ovary occur at any period of life, from birth 
to eighty years of age, and are to be regarded as the most common 



DIAGNOSIS OF DISEASES OF THE OVARY 447 

abdominal tumor in girls and young women. The rate of growth 
varies from a few months to many years in attaining the maxi- 
mum size. They are rarely larger than the patient's head, and 
may be self-limiting in their growth. As a rule, adhesions bind 
the cyst to the intestine. Suppuration and malignant degeneration 
are the peculiar characteristics of dermoid cysts of the ovary. 

CONNECTIVE-TISSUE NEW-FORMATIONS OF THE OVARY. 

Fibroma, myoma, myxoma, enchondroma, osteoma, angioma, 
lymphangioma . 

Fibroma of the Ovary. Of the connective-tissue tumors of the 
ovary, fibroma is the most frequent. They are found with about 
equal frequency between the ages of twenty and fifty, and have 
been met with as early as ten or as late as eighty years of age. 
Peterson {American Gynecology, vol. i.. No. 1) reports 2 of his own 
cases and reviews the literature of 82 cases. The largest number 
occurred between the ages of forty and fifty years. Peterson finds 
no marked menstrual irregularities in these cases. The growth 
is usually slow, but may be quite rapid. In more than half of the 
cases pain was experienced. Ascites was present in about 40 per 
cent, of the cases. No satisfactory explanation is given for its 
occurrence. In 13 per cent, there were calcareous deposits in the 
tumors, and cystic spaces were common. 

Orthmann classifies fibroids of the ovary as superficial and diffuse. 

a. Superficial fibroids are commonly small, rarely larger than a 
walnut. They are single or multiple, and sessile or pedunculated 
in their attachment to the tunica albuginea. Their consistency is 
firm, and the external surface is smooth or furrowed. On cross- 
section whorls and bands of fibres are seen. Germinal epithelium 
covers the surface of the tumor. 

h. Diffuse fibroids have rarely grown larger than a man's head. 
Clemens reported one weighing 40 kilos. The contour varies from 
round and smooth to irregular and nodular. The amount of blood 
supply is variable, and hence the color of the tumor varies from a 
pale green to a yellowish-red. Unless there are degenerative changes 
their consistency is uniformly firm. 

Adenofibroma of the ovary is an occasional finding and consists of 
glandular tissue in a fibrous framework. 



448 SPECIAL DIAGNOSIS 

Myoma of the Ovary. The origin of myoma of the ovary 
probably is in the muscle fibres of the vessel walls and the ovarian 
ligament. They are rare. None larger than a man's fist has been 
reported. In general appearance they closely resemble fibroids. 

Myxoma ovarii appears as a degenerative form of an ovarian 
tumor, not as a primary growth. 

Enchondroma and osteoma are secondary changes in pre-existing 
ovarian tumors. 

Angioma and lymphangioma are extremely rare. A congenital 
angioma is described by Orth. 

SARCOMA OF THE OVARY. 

In 66,190 malignant tumors of the ovary 96 were sarcomata. 
They are found at any period of life, from birth to old age. The 
periods of puberty and the menopause are the most frequent 
(Zangemeister). Doran found a sarcoma of the ovary in a seven 
months' foetus; Heinrichs reported one in a woman aged seventy- 
four years. According to Temesvary, the average age of the patient 
is thirty-two years. Pfannenstiel found sarcoma of the ovary most 
frequent between the ages of twenty-one and thirty. In 25 cases 
Pick found 10 occurring before twenty years of age. 

Sutton says sarcoma of the ovary differs from sarcoma found 
elsewhere in that both ovaries are often simultaneously affected. 
In 121 cases in the literature, I found 42, or about one-third of the 
number, in which both ovaries were involved. 

INIany so-called fibroids of the ovary are undoubtedly sarcomata. 
Russel and Shenck described a sarcoma springing from the theca 
interna. In form they may resemble a large ovary or are very 
irregular and nodular. Their consistency varies from firm to soft 
and the color from pale gray to reddish- white. The rate of growth 
is variable, the softer tumors growing more rapidly. Chrobak saw 
a sarcoma of the ovary grow to the size of a five months' pregnancy 
in a few months. 

The entire ovary is usually involved, and both ovaries in about 
one-half of the cases. 

Both round and spindle sarcoma cells compose the tumor. About 
one-third are cystic. Sarcomatous degeneration of dermoid cysts 
is described. Metastasis occurs later in sarcoma than in carcinoma 



DIAGNOSIS OF DISEASES OF THE OVARY 449 

of the ovary. INIetastatic growths are found in order of frequency 
in the peritoneum, omentum, wall of the stomach, pleura, lungs, 
uterus, liver, diaphragm, retrovaginal connective tissue, mediasti- 
num, tubes, intestines, and kidney (Temesvary). 

A myxomatous degeneration of sarcomatous tissue is occasionally 
observed. 

ENDOTHELIOMA OF THE OVARY. 

Marchand and Leopold first observed malignant new-formations 
of the ovary arising from the endothelium of bloodvessels. They 
are also known to arise from the lymph vessels. Few have been 
recognized, but doubtless many pass for carcinoma and sarcoma. 

PAROVARIAN CYSTS. 

The parovarium consists of a series of tubules lying between the 
layers of the mesosalpinx. When the mesosalpinx is stretched and 
held between the eye and the light, the tubules are seen as narrow 

Fig. 184 




Parovarian cyst. Between the tube and ovary is a thin-walled, transparent cyst the size 
of an almond. It lies between the layers of the broad ligament, and was developed from a 
parovarian tubule. 

cords running in parallel lines from the hilum of the ovary to a 
longitudinal tubule lying parallel to the tube and immediately 
beneath it (Gartner's duct). The tubules are lined with ciliated 
epithelium. The parovarium is homologous with the vasa affer- 
entia and epididymis of the testis. It is composed of the persistent 
excretory ducts of the Wolffian body. 

As a rule, there are twelve tubules. The tubule running parallel 

29 



450 



SPECIAL DIAGNOSIS 



to the Fallopian tube and at right angles to the parovarian tubules 
is the duct of Gartner, which in exceptional cases may be traced to 
the vagina. 

Cysts arising from the parovarium, the so-called parovarian cysts, 
are of common occurrence. As the cyst develops the layers of the 
mesosalpinx are unfolded, the tube is crowded upward and runs 
over the cyst, and the ovary is crowded downward. The Fallopian 
tube is greatly elongated in large cysts, but the lumen is seldom 

Fig. 185 




Parovarian cyst. The cyst is almost round, the wall is thin and transparent. There is 
but a single cavity containing a watery fluid of low specific gravity. Covering the cyst is a 
thin, vascular membrane which appears to form a part of the cyst wall. The vascularity of 
the cyst wall is a characteristic feature. The Fallopian tube is stretched over the cyst, and 
the ovary is crowded to the side. 



obliterated. The wall of the cyst is at first thin and transparent, 
later thick and non-transparent. The epithelium lining the cyst is 
columnar and usually ciliated in the small cysts, while later the 
epithelium is stratified and flat. In the very large cysts the epithe- 
lium may wholly disappear through pressure. The fluid contents 
is clear and watery, the reaction is slightly alkaline, and the specific 
gravity 1002 to 1010, 



DIAGNOSIS OF DISEASES OF THE OVABY 451 

No parovarian cyst has been recorded in an individual under six- 
teen years of age (Sutton). They are supposed to form about 10 
per cent, of ovarian tumors. Parovarian tumors are rarely adher- 
ent; they seldom suppurate, and are less liable to axial rotation 
than are ovarian cysts, because they are usually fixed by the broad 
hgament and seldom have a pedicle. 

The Clinical Diagnosis of New-formations of the Ovary. 
In the diagnosis of ovarian tumors it is of the greatest importance 
to recognize a pedicle connecting the tumor to the horn of the 
uterus. The pedicle is composed of the Fallopian tube, broad 
ligament, and ovarian ligament. A short, thick pedicle holds the 
tumor close to the uterus, while a long, slender pedicle permits 
considerable separation. The length and thickness of the pedicle 
are not proportionate to the size of the tumor. When, as occasion- 
ally happens, the tumor grows in the direction of the mesovarium 
and broad ligament, it becomes intraligamentous. An ovarian 
tumor may be partly within the broad ligament and partly within 
the free peritoneal cavity. Having grown between the layers of 
the broad ligament, the tumor may burrow to the left behind the 
sigmoid flexure, to the right behind the csecum, into the parametric 
tissue behind the uterus, or between the bladder and abdominal 
wall underneath the peritoneum. 

In discussing the diagnosis of ovarian tumors we will adopt the 
classification of Winter, devised by him for convenience of descrip- 
tion. It is as follows: 

1. Small ovarian tumors, which lie wholly or in part within the 
pelvis. 

2. Medium-sized ovarian tumors, which have grown into the 
abdominal cavity, which have not grown beyond the size of a 
man's head, and have not risen to the arch of the ribs. 

3. Large ovarian tumors, which rise to the arch of the ribs and 
are in intimate relation to the liver, kidney, and spleen. 

The Diagnosis of Small Ovarian Tumors Which Lie Wholly or in 
Part within the Pelvis. The tumor may be closely crowded to the 
uterus — so close that no pedicle is detected. It is always possible 
in a vaginal examination to insert the finger between the supra- 
vaginal portion of the cervix and the tumor. When the tumor lies 
behind the uterus it is especially difficult to separately outline the 
two. Ovarian cysts are round, the surface is usually smooth, and 



452 



SPECIAL DIAGNOSIS 



fluctuation is well marked. They are not tender to pressure unless 
complicated by adhesions or other inflammatory lesions. 

Solid tumors are usually more uneven in outline and have a firm 
consistency. Cystic tumors with thick walls and surrounded by 
an inflammatory exudate may give the impression of solid tumor 
growths. The uterus rriay be crowded to the opposite side. 

Differential Diagnosis. To diagnose small tumors of the ovary 
from cystic degeneration, chronic ovaritis, hsematoma, and abscess, 
it is necessary to consider the history of the onset and the clinical 
course. Sensitiveness to pressure speaks for inflammatory enlarge- 
ments, as does fixation. Inflammatory enlargements of the ovary 
do not show steady growth as do new-formations, and, furthermore, 
they are more likely to be bilateral. In inflammatory swellings of 
the ovary the accompanying tube is often diseased, and evidences 
of pelvic peritonitis are frequently found. The effect of local 
applications is reduction of the size of inflammatory swellings of the 
ovary, while such treatments have no effect upon new-growths. 

Cystic degeneration of the ovaxy is very constantly associated with 
chronic ovaritis, and is to be distinguished from new-formations of 
the ovary by its small size and tendency to be self-limited in growth. 
Such ovaries are rarely larger than a hen's egg. 

Uterine Fibroids. It is easy to mistake pedunculated subperi- 
toneal fibroids of the uterus for tumors of the ovary. 



Uterine Fibroids. 

1. Rarely occur in early life. 

2. Rarely grow after the menopause. 

3. Rate of growth is slow. 

4. Consistency usually firm. 

5. Intimately attached to the uterus. 

6. Tumor may be attached to any portion 

of the uterus. 

7. Pedicle usually short and thick. 

8. Uterus usually increased in length. 

9. May find both ovaries normal. 

10. Venous murmur heard in 50 per cent. 

of large fibroids. 

11. Menorrhagia common. 

12. Functions of the bladder and rectum 

often disturbed. 



Ovarian Cysts. 

1. May occur in infancy. 

2. Often continue to grow after the meno- 

pause. 

3. Rate of growth is usually more rapid. 

4. Fluctuating. 

5. Less intimately associated with the 

uterus. 

6. Tumor connected with the uterine horn. 

7. Pedicle may be long and slender. 

8. No increase in the length of the uterus. 

9. One or both ovaries abnormal. 

10. Venous murmur seldom heard. 

11. Not common. 

12. Not often disturbed. 



It must be remembered that uterine fibroids may appear to fluc- 
tuate similarly to a cyst with gelatinous fluid. When doubt exists 
after all of the above points are considered, an exploratory incision 
should be made. 



DIAGNOSIS OF DISEASES OF THE OVABY 453 

Tubal Pregnancy. See respective chapter. 

Serous perimetric exudates may become sharply circumscribed, 
shghtly or not at all tender to pressure, and may fluctuate from 
contained fluid. In the early stage the exudate may collect in the 
pouch of Douglas, and from its form and consistency it may be mis- 
taken for an ovarian tumor. Such exudates are rounded below and 
flat above, while ovarian cysts are round throughout their entire 
circumference. The consistency may show variations at different 
points, while in ovarian cysts it is usually uniform throughout. The 
exudate blends with the surrounding structures, and is inseparably 
connected with the uterus. 

The history of infection, the rapid development of the mass, and 
the tendency to remain stationary, or to decrease in size, are im- 
portant factors in the differential diagnosis of perimetric exudates 
from ovarian cysts. 

Parametric exudates can usually be differentiated from ovarian 
cysts by the history of infection. This will point to an inflamma- 
tory origin. The location of the mass in the connective tissue in 
close proximity to the vaginal wall is characteristic of pelvic cellu- 
litis. Ovarian tumors lie on a higher level. The consistency of 
an inflammatory exudate changes from time to time, becoming 
firmer and irregular, while the consistency of ovarian cysts is con- 
stant. It is often possible to palpate both ovaries apart from the 
pelvic exudate. 

The intimate connection with the uterus, the ill-defined outline, 
the immobility and tenderness to pressure, the history of infection, 
and the sudden development of the mass, together with its tendency 
to become smaller as time goes on, are significant points in favor 
of the diagnosis of a pelvic exudate. 

Pericsscal Abscess. A suppurating cyst of the ovary may be con- 
fused with an abscess about the caecum. A history of one or more 
attacks of appendicitis and existing intestinal disorders will be sug- 
gestive. The abscess is largely confined to the right iliac region, 
and extends downward to the uterus rather than upward from the 
uterus. 

Retrouterine hsematocele occupies the pouch of Douglas, and may 
be so moulded as to suggest an ovarian tumor. A hsematocele is 
less tense and elastic, and does not fluctuate. There is no attach- 
ment by a pedicle to the horn of the uterus, and it may be possible 



454 SPECIAL DIAGNOSIS 

to palpate both ovaries apart from the mass. A history of ruptured 
tubal pregnancy is often elicited. An exploratory puncture or 
incision will disclose the blood. 

Intraligamentous haematoma in its early development occupies a 
position altogether impossible for an ovarian tumor, and, later, as 
it dissects around the uterus, it cannot be confounded with an 
ovarian tumor. The low situation of the mass, its ill-defined out- 
line, the absence of fluctuation, its tendency to become smaller 
instead of progressively enlarging, and, finally, an exploratory 
puncture or incision will determine the diagnosis. There is usually 
a history of ectopic pregnancy with rupture of the gestation sac. 

A retro flexed pregnant uterus has been mistaken for an ovarian 
cyst. The usual signs of pregnancy are to be considered. In 
ovarian cysts it is possible to have amenorrhoea, enlargement of the 
mamma?, secretion of colostrum, discoloration of the cervix and 
vagina, and nausea. These signs, together with a rapidly growing 
abdominal tumor, might suggest pregnancy. 

The rate of growth of a pregnant uterus is more rapid than that 
of an ovarian cyst. Its consistency is soft and elastic, as contrasted 
with the tense elasticity of an ovarian cyst. So long as there is a 
suspicion of pregnancy the sound should not be employed. When 
in doubt as to the diagnosis, and immediate interference is not 
demanded, it is well to keep the patient under observation for 
several weeks to note the progress of the tumor and the develop- 
ment of positive signs of pregnancy. 

THE DIAGNOSIS OF OVARIAN TUMORS OF MEDIUM SIZE. 

A tumor lying at the brim of the pelvis that is round or oval, 
sharply outlined and fluctuating, is in all probability an ovarian 
cyst. If it can be demonstrated that the tumor is attached to the 
horn of the uterus by a pedicle, the diagnosis is confirmed. It is 
most essential to recognize the pedicle, and this is usually possible 
where the conditions for examination are favorable. Where the 
pedicle is difficult to palpate, Hagar advises traction on the cervix 
by a tenaculum while a rectoabdominal examination is carried 
out. 

Winter further advises traction on the tumor by an assistant, as 
shown in Plate X. In this manner the pedicle is made taut and 



I>IAGNOSIS OF DISEASES OF THE OVARY 455 

can be more readily recognized. Where the pedicle cannot be 
palpated, the diagnosis must rest upon the consistency and general 
outhne of the uterus. 

Pregnancy in the second and third trimester can only be confounded 
with an ovarian tumor when there is no evidence of the presence of 
a foetus. There will be still greater uncertainty in the diagnosis 
when it is not possible to demonstrate the direct continuity of cervix 
and body because of the high position of the uterus. 

The uterine souffle is seldom heard in ovarian cysts, and will 
speak for a pregnant uterus or a solid tumor. The finding of the 
round ligaments running to the tumor will establish the diagnosis. 

Advanced Ectopic Pregnancy. The history of pregnancy, together 
with the finding of an abdominal tumor of unequal soft consistency 
and absence of fluctuation, will suffice for the exclusion of an ovarian 
cyst. Where the foetus is living it is scarcely possible to mistake 
the tumor for an ovarian cyst. With the death of the foetus all 
signs of pregnancy may disappear. The uterus in an ovarian cyst 
is normal in size, while in advanced ectopic pregnancy it fairly 
resembles a pregnant uterus at the third month. 

A distended bladder may resemble an ovarian cyst in general out- 
line, position, and consistency. In every pelvic examination for 
whatever lesion, it is always advisable to make sure that the bladder 
is empty. If this rule is observed there will be no question as to 
the differential diagnosis of an ovarian cyst from a greatly distended 
bladder. When such a question arises the catheter will obviate all 
possible error. 

Tumors of the omentum rarely simulate ovarian tumors. They 
are seldom so sharply circumscribed and rounded, and are not con- 
nected to the uterus by a pedicle. The finding of the ovaries apart 
from the tumor will exclude the possibility of an ovarian tumor. 
Omental cysts have been tapped for ovarian cysts. 

Echinococcus cysts of the pelvis form a rounded cystic tumor that 
closely resembles an ovarian cyst. The presence of a tumor of the 
liver speaks in favor of echinococci, but an absolute diagnosis is 
only made by an exploratory puncture and the finding of the 
booklets. 

Parovarian cysts have thin walls and are less tense than ovarian 
cysts. Unless the ovary can be palpated distinct from the cyst a 
clinical diagnosis cannot be made with certainty. 



456 SPECIAL DIAGNOSIS 

Phantom tumors of the abdominal wall, caused by muscular con- 
traction, may simulate an ovarian cyst in form and consistency. 
The swelling has no connection with the uterus and will disappear 
under anaesthesia. 



THE DIAGNOSIS OF LARGE OVARIAN TUMORS FILLING 
THE ABDOMINAL CAVITY. 

It is often quite impossible to palpate the pedicle because of the 
close proximity of the large tumor to the uterus. When it is demon- 
strated that the swelling is a cystic tumor and not free fluid, the 
diagnosis of an ovarian cyst is highly presumptive, because it is 
most unusual for a cystic tumor of such size to grow from any other 
source than the ovary. The superficial veins of the abdominal wall 
are distended, and markings resembling striae gravidarum are 
usually seen over the abdomen. The percussion note is dull over 
the swelling, and tympanitic in the flanks and over the stomach 
where the intestine and stomach have been crowded by the tumor. 
Changing the position of the patient does not alter the outline of 
the area of dulness as it does in free ascites. 

Fluctuation is easily demonstrated. Because of the great disten- 
tion of the abdomen it is difficult to outline the uterus. When 
pregnancy can be excluded the uterine sound will determine the 
position of the uterus. In cysts of extreme size the upper border 
lies beneath the sternum and ribs, bulging them forward; the 
tympanitic note of the transverse colon and stomach is lost. The 
splenic dulness is lost, the liver dulness cannot be defined from that 
of the tumor, and the heart and lungs are pressed upward. The 
abdomen is symmetrically enlarged, hence measurements are of no 
value in the largest cysts. Those of smaller size present an asym- 
metrical enlargement which can be demonstrated by inspection and 
by certain measurements. These measurements are taken from the 
umbilicus to the anterior superior spine of the ilium, and from the 
linea alba to the spine of the vertebrae. A comparison of the meas- 
urements of the two sides will afford reliable information. Auscul- 
tation is of little service. A bruit is sometimes heard, and will 
serve to differentiate the cyst from ascites. 

Differential Diagnosis. Free ascites is very often mistaken for 
large ovarian cysts. Cases occur where a diagnosis cannot be 



DIAGNOSIS OF DISEASES OF THE OVARY 



457 



made until the abdomen is opened. Still greater difficulty arises 
when an ovarian cyst is associated with ascites. Much can be 
ascertained from inspection of the distended abdomen. 



Ascites. 

1. Diseases of the heart, lungs, liver, and 

peritoneum to account for the presence 
of the fluid. 

2. Rapid development. 

3. Inspection of abdomen. 

a. Enlargement symmetrical. 

6. Flattening anteriorly and bulging in 
the flanks with patient on her back. 

c. Lower portion of abdomen bulges and 

epigastrium is flattened with patient 
erect. 

d. Navel prominent and thin. 

e. Costal arch does not bulge. 

4. Percussion of the abdomen. 

a. Dulness in flanks. 
6. Tympany in median Une. 
c. Change of area of dulness by change 
of position of patient. 

5. Palpation of abdomen. 

a. No outUne of tumor can be palpated. 
h. Fluctuation in aU vaginal fornices. 

6. Exploratory puncture. 

Contains serous flmd. 

7. Hydragogues and diuretics temporarily 

improve the condition. 



Large Ovarian Cyst. 



1. Absent. 



2. Development usually slow. 

3. Inspection of abdomen. 

a. Enlargement asymmetrical unless the 

entire abdomen is filled. 
h. Round anteriorly and flat in the flanks 

with patient on her back. 

c. No change in the outline of the tumor 

by change of position of patient. 

d. Navel not prominent. 

e. Costal arch bulges. 

4. Percussion of abdomen. 

a. Dulness over abdominal prominence. 
&. Tympany in flanks and epigastrium, 
c. No such change. 

5. Palpation of abdomen. 

a. Outline palpated. 
h. More hmited. 

6. Exploratory puncture. 

Contains serum or mucus. 

7. Have no effect. 



The percussion note is of greatest value in differentiating free 
from encysted fluid. The area of dulness increases as the fluid 
collects, and is last to disappear in the epigastrium. In ascites of 
extreme grade there may be no area of tympany, and the same may 
be true of very large ovarian cysts. If the mesentery is short, the 
tympanitic note disappears early; if long, so as to permit the 
bowels to float on the surface of the ascitic fluid, or to be crowded 
in advance of the cyst, the tympany can be demonstrated until 
the abdomen is overdistended. 

Certain fallacies must be guarded against. A very short mesen- 
tery or the presence of adhesions may confine the intestine to the 
flanks in free ascites and give a tympanitic note in this region. In 
ovarian cyst the bowel may be adherent to the anterior abdominal 
wall and give a tympanitic note in the median line. Gas generated 
within the cyst may give a tympanitic note. Again, the absence of 
gas within the bowel may give a dull note where tympany would 
otherwise be found. 

In an ovarian cyst the percussion note is always dull over the 



458 



SPECIAL DIAGNOSIS 



tumor, whether the percussion is superficial or deep, while in ascites 
superficial percussion may be tympanitic and deep percussion dull. 



Fig. 186 






IIMTESTINAI 
RESONAMCH 




Free fluid in the abdominal cavity. The dark Unes show the area of dulness on percussion 

with the patient lying on her back. 



DIAGNOSTS OF DISEASES OF THE OVARY 



459 



It is especially difficult to differentiate between ascites and a 
thin-walled cyst, such as a large parovarian cyst. In the latter 



Fig. 187 




Large ovarian cyst. The dark lines show the area of dulness on percussion in any position 

the patient may assume. 



460 SPECIAL DlAOyoSIS 

the fluid may gravitate to the dependent portions of the abdomen, 
and it may not be possible to outhne the tumor by palpation. An 
exploratory incision may alone clear up the diagnosis. 

As an aid to the differential diagnosis of ascites and ovarian cysts, 
Landau advises putting the patient in the lithotomy position and 
elevating the hips. If there is a large quantity of free fluid in the 
abdominal cavity, the uterus, in an abdominovaginal manipulation, 
may be demonstrated to lie upon a water-cushion. 

Pancreatic Cysts. No confusion should arise in the early develop- 
ment of pancreatic cysts. They take their origin in the region of 
the pancreas and grow from above downward. The most promi- 
nent portion of the tumor is located in the region of the navel. 

It is possible for a small or moderate-sized ovarian cyst with a 
long pedicle to occupy a similar position. Such a cyst is usually 
more movable than a pancreatic cyst, and the demonstration of 
its attachment to the uterus by a pedicle will determine the diag- 
nosis. 

In doubtful cases an exploratory puncture, together with a chem- 
ical analysis of the aspirated fluid, will identify a pancreatic cyst. 
The danger of perforating the stomach is to be borne in mind. 

Splenic Tumor. It is possible for a tumor of the spleen to extend 
to the inlet of the pelvis, and when cystic (echinococcus) an ovarian 
cyst may be diagnosed. Most splenic tumors are solid, and these 
are not likely to be mistaken for ovarian tumors. A splenic tumor 
grows from above downward, while an ovarian tumor grows from 
below upward. The finding of a pedicle connecting the tumor with 
the horn of the uterus identifies it as ovarian in origin. An analysis 
of the blood will often disclose the nature of a splenic tumor (splenic 
leukaemia, malaria) . The notched border and the respiratory move- 
ments of the spleen are significant. A number of cases have been 
reported in which the spleen of about normal size has occupied the 
pelvis and has been mistaken for solid tumors of the ovary. It is 
important in all such cases to seek for a pedicle connecting the . 
tumor with the horn of the uterus. As a last resort an exploratory 
incision may be made. 

Tumors of the Liver. It is possible for tumors of the liver to 
reach to the inlet of the pelvis. An ovarian tumor, because of its 
great size or long pedicle, may reach to the right costal arch and 
the tumor and liver become one inseparable mass. 



DIAGNOSIS OF DISEASES OF THE OVABY 461 

A uniform enlargement of the liver should be recognized by its 
sharp lower border and by the characteristic fissure separating the 
right from the left lobe. The mass should move with respiration, 
a fact not observed in ovarian tumors. An irregular enlargement of 
the liver, as from echinococcus cysts, abscess, and new-formations, 
is more likely to be mistaken for an ovarian tumor than is a uniform 
enlargement. Here, as at all times, it is essential to determine the 
relation of the tumor to the uterus, whether or not there exists a 
pedicle. In pedunculated tumors of the liver the greatest mobility 
is at the lower portion of the growth, while in freely movable ovarian 
tumors the greatest mobility is at the upper portion of the tumor. 

Fatty Tumors. Enormous fatty tumors may spring from the 
omentum and subserous tissue, and suggest the possible presence 
of ovarian tumors. 

A distended gall-bladder containing eleven pints of fluid was 
operated upon by Lawson Tait, who mistook it for an ovarian cyst. 

A chylous cyst of the mesentery may attain an enormous size, 
and closely simulate an ovarian cyst. 

Obesity. A very thick abdominal wall may suggest the presence 
of an ovarian tumor. It may be impossible to say that an ovarian 
cyst does not exist without making an exploratory incision. 

Allantoic or urachus cysts may give rise to suspicion of an ovarian 
cyst. They may attain a large size, and are always found in the 
median line between the abdominal wall and peritoneum. 

Hydronephrosis has been mistaken for ovarian cysts. A hydro- 
nephrosis may occupy the pelvis and an ovarian tumor may occupy 
the region of the kidney. Moreover, a hydronephrosis and an 
ovarian tumor may coexist. 

The characteristic physical signs of renal tumors can usually be 
relied upon. The colon lying in front of the kidney gives a tym- 
panitic note on light percussion. In exceptional cases the bowel 
may lie in front of an ovarian cyst. In hydronephrosis the tumor 
may intermit, and such diminution in size is accompanied by an 
abundant flow of urine. Examination of the urine may disclose 
important facts. It is possible for an ovarian cyst to rupture, and 
this in turn be followed by diuresis. Hydronephrosis is rarely so 
movable as an ovarian cyst. 

The ovarian cyst when large and fixed may cause hydronephrosis 
by pressure upon the kidney or ureter. 



462 SPECIAL DIAGNOSIS 

The diagnosis of bilateral ovarian tumors is readily made when 
from either tumor a pedicle is traced to the uterine horns. The 
smaller the tumor the easier the diagnosis. In very large tumors 
the diagnosis may be impossible. When in the absence of preg- 
nancy and in the presence of a large cystic tumor of the abdomen 
the menses are suppressed, a bilateral ovarian tumor is suspected. 
The two tumors are rarely of the same size, and seldom lie on the 
same level. A furrow may separate the two, and two separate and 
distinct percussion waves may be elicited. The tumors may be 
moved separately by bimanual manipulation. Not infrequently the 
diagnosis is deferred until an exploratory incision has been made. 

INTRALIGAMENTOUS DEVELOPMENT OF OVARIAN TUMORS. 

It is not always possible to recognize an intraligamentous tumor 
of the ovary without opening the abdomen. Such tumors lie within 
the two layers of the broad ligament in close proximity to the uterus 
and are usually firmly fixed. No pedicle can be palpated. In very 
exceptional cases the tumor will distend the broad ligament and 
draw it out into a broad pedicle. Such tumors have some degree 
of mobility. Intraligamentous tumors of the ovary rarely grow to a 
large size. The uterus and tumor appear as one mass, or the uterus 
may be distinctly outlined from the tumor. In exceptional cases the 
tumor may burrow beneath the peritoneum behind or to the front of 
the uterus. When bilateral the uterus may be lifted out of the pelvis. 

Ovarian Cysts. Parovarian Cysts. 

1. Develop from the oiiphoron, 1. Develop from the parovarium. 

2. Commonly multilocular. 2. Usually unilocular. 

3. May reach enormous size. 3. Seldom large. 

4. Growth usually rapid. 4. Usually slow. 

5. Usually pedunculated and movable. 5. Rarely pedunculated and usually fixed. 

6. Adhesions about cyst common. 6. Adhesions not common. 

7. Tapping not curative. 7. Often curative. 

8. Character of contents: contains albumin; 8. Character of contents: little or no albu- 

is mucinous or thin and watery; clear min; clear, watery fluid of sp. gr. 103 to 

and transparent, or coffee colored. 1010. 

9. Papillomatous growths common. 9. Not common. 

10. Rarely intraligamentous. 10. Always. 

11. Tendency to become malignant. 11. Seldom becomes malignant. 

12. Rarely self-Umited in growth. 12. Self-limited in growth. 

13. No ovary visible. 13. Ovary attached to the periphery of cyst. 

14. Bloodvessels seldom seen to radiate over 14. Large, radiating bloodvessels frequently 

the surface of the cyst. seen on the surface of the cyst. 

Adherent Tumors of the Ovary. From an operative point of view 
it is very important to recognize the presence of adhesions. It is 



? 



DIAGNOSIS OF DISEASES OF THE OVARY 463 

manifestly more difficult to recognizee adhesions in large cysts which 
have little or no range of motion than in small cysts which under 
ordinary conditions are freely movable. Adhesions are recognized 
by the immobility of the tumor, its greater or less degree of tender- 
ness, and, in exceptional cases, by palpating the adhesions in a con- 
joined examination. 

In large cysts the respiratory excursions are less marked when 
adhesions are present. It may be impossible to determine the 
degree of mobility unless an ansesthetic is administered. When the 
cyst is adherent to the parietal peritoneum the abdominal wall 
moves w^ith the cyst; friction sounds and fremitus may be heard. 
Adhesions to the mesentery and intestine may permit free mobility 
of the tumor. 

Torsion of the Pedicle. It is of the greatest importance to make 
an early diagnosis of torsion of the pedicle. Delay in recognizing 
the condition may terminate disastrously. 

Certain conditions are recognized as predisposing to this event, 
namely, a long pedicle, ascitic fluid, sudden alterations in the intra- 
abdominal pressure from overexertion, falls, and blows, a growing 
pregnant uterus, and the emptying of a pregnant uterus. Torsion 
of the pedicle is said to occur in about 10 per cent, of ovarian and 
parovarian tumors. 

When both ovaries are cystic the liability to torsion is about as 
great as when a single cyst complicates pregnancy. 

Twisting of the pedicle occurs in all ages and in all kinds of 
ovarian tumors. Thornton observed it in a thirteen-year-old girl, 
and Potter in a woman aged eighty-three years. Dermoid cysts 
are particularly liable to this accident. 

As a result of torsion of the pedicle, many grave complications 
may arise. Hemorrhage into the cavity of the cyst may rapidly 
distend it, even to the point of bursting, and may prove fatal. 
Gangrene of the cyst will rapidly follow when the circulation is 
completely shut off; peritonitis is then inevitable. If adhesions 
convey sufficient blood to the cyst, gangrene will not follow, and the 
cyst may remain intact. It is possible for the cyst to be entirely 
severed from the uterus. In order that the cyst may not undergo 
speedy destruction, adhesions must convey a sufficient supply of 
blood. The tightness of the twist varies with the thickness of the 
pedicle. Tumors of medium size are most liable to this accident. 



464 



SPECIAL DIAGNOSIS 



The diagnosis cannot be made with certainty. Having previously 
recognized a pedunculated tumor of the ovary, torsion of the pedicle 
will be suspected, when the patient is seized with severe pain in the 
region of the tumor, and at the same time the tumor increases in 
size and is tender to pressure. Collapse may follow immediately 
upon the twisting of the pedicle. An absolute diagnosis must be 
reserved for an exploratory incision. Operative interference must 
be advised upon a provisional diagnosis: the expectant plan of 
treatment is not to be followed. 

Fig. 188 




An adherent multilocular cyst crowding the uterus into extreme anteversipn. 



A limited degree of torsion may cause no symptoms; there is 
pain of variable intensity followed by symptoms of peritonitis, 
including fever, rapid pulse, tympany, and abdominal tenderness. 
Peritonitis complicating ovarian cysts is most often the result of 
secondary infection of the cyst. Torsion of the pedicle of an 
ovarian tumor must be differentiated from hepatic colic, renal colic, 
intestinal obstruction, strangulated hernia, appendicitis, ruptured 
tubal pregnancy, and rupture of a sactosalpinx. 



DIAGNOSIS OF DISEASES OF THE OVABY 465 

Rupture of an ovarian cyst results from direct violence, torsion of 
the pedicle, degeneration of the cyst wall, hemorrhage within the 
cyst and in the wall of the cyst. Spontaneous rupture from thin- 
ning of the cyst wall has been reported. 

When the cyst ruptures there is a feeling of relief from pressure; 
the cyst is no longer evident, but if sufficient fluid has escaped the 
contents may be recognized free in the abdominal cavity. From 
absorption of the contained fluid the temperature may be slightly 
elevated and the bowels and kidneys become unusually active. 
The cyst may rapidly refill. 

Leakage of the cyst is a term implying a slow and limited empty- 
ing of a cyst into the peritoneal cavity. The daughter cysts, which 
so often bulge on the surface of the parent cysts, have an extremely 
thin wall, which may give way at some point and permit the con- 
tents to be discharged into the peritoneal cavity. Secondary cysts 
also rupture into the parent cyst, and in this manner a multilocular 
cyst may be converted into a unilocular cyst. 

Rupture of the cyst may occasion hemorrhage that is either 
confined within the cyst or that escapes into the free peritoneal 
cavity. The hemorrhage may prove fatal; this is particularly true 
of rupture following upon torsion of the pedicle. The escape of the 
fluid from the cyst is often hindered by the plugging of the rent 
with a daughter cyst. 

Rupture of an ovarian cyst into hollow viscera is possible. Der- 
moid cysts are particularly liable to adhere to the bowel and to 
subsequently rupture into it; such cysts are invariably infected. 

Hemorrhage into the cyst is the common result of torsion of the 
pedicle, and the symptoms are usually masked by those caused by 
the torsion. Puncture and direct violence are additional causes of 
hemorrhage. 

A moderate hemorrhage may cause no clinical symptoms. When 
the loss of blood is considerable the symptoms are those of internal 
hemorrhage, together with a rapid increase in the size of the tumor, 
pain, and high tension in the cyst. 

Suppuration of an ovarian cyst was formerly believed to follow 
tapping and the accidental admission of air. This is possible, 
but more often suppuration occurs independent of such events. 
Dermoid cysts are particularly liable to suppuration. The 
infected cysts are invariably adherent to the bowel, bladder, or 



466 SPECIAL DIAGNOSIS 

vagina, and through these adhesions the infection is conveyed to 
the cyst. 

In acute cases the patient dies from septic infection, unless opera- 
tive interference is instituted. The symptoms of acute suppuration 
are characteristic. The temperature is elevated and irregular, the 
pulse is rapid and feeble, exhaustion and emaciation rapidly develop. 
The cyst increases in size, and is very tender to pressure. Sutton 
has observed the temperature to become subnormal in long-standing 
cases with foul-smelling pus. 

When gas generates in the cyst the dull percussion note gives 
place to tympany. After suppuration the cyst may discharge its 
contents into the bowel, bladder, vagina, rectum, peritoneal cavity, 
or through the abdominal wall. 

When a fistulous communication is established between the cyst 
and a hollow viscus, or the abdominal wall, the discharge of pus 
may be prolonged indefinitely, and the patient finally become 
exhausted. Fragments of bone, teeth, and hair have sloughed into 
the bladder from an adherent dermoid cyst. These fragments may 
become the nuclei of vesical calculi. 

It is most unusual for such fistulse to close spontaneously. The 
infection frequently travels to the cyst by way of the Fallopian 
tube. From an infected tube adhesions may develop between the 
cyst and the omentum, bowel, bladder, and abdominal wall. In a 
similar manner the appendix is the starting point of an infection in 
and about the cyst. Adhesions between the appendix and cyst must 
be looked for in the course of the removal of the cyst, otherwise 
death may be caused by tearing through the appendix and bowel. 

The diagnosis of malignant degeneration of an ovarian 
tumor is of the utmost importance, but unfortunately cannot be 
made with certainty without a microscopic examination. 

Bilateral ovarian tumors of the ovary are often malignant, but 
all forms of benign tumors of the ovary are occasionally bilateral. 
The presence of ascites is also suggestive of malignancy, yet malig- 
nant tumors of the ovary may exist without ascites, and all forms 
of new-growths of the ovary may be associated with ascites; this is 
particularly true of papillomatous growths. 

The most suggestive signs of maUgnant degeneration of new- 
growths of the ovary are rapid growth, immobility of the tumor, 
and their firm, nodular character. Partial development within the 



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DIAGNOSIS OF DISEASES OF THE OVABY 467 

broad ligament Is also said to be suggestive of malignant degenera- 
tion. Metastatic growths may be found on the peritoneum and in 
the viscera. Finally, an exploratory incision will be required in 
many cases, and even then the diagnosis must sometimes be deferred 
for a microscopic examination. The consideration of the age of 
the patient is not of great importance in that malignant tumors of 
the ovary are known at all ages from the time of puberty. 

OVARIAN TUMORS COMPLICATING PREGNANCY. 

All forms of ovarian tumors may complicate pregnancy. Prob- 
ably the most frequent are the dermoids, because they occur early 
in life, grow slowly, and are very often fixed in the pelvis, where 
they offer obstruction to labor. 

The dangers to be apprehended during pregnancy are: 

1. Axial rotation of the tumor. 

2. Rupture of the cyst. 

3. Incarceration of the tumor in the pelvis. 

4. Impediment to respiration when large. 

5. Interference with the functions of the abdominal viscera from 
pressure. 

The dangers to he apprehended in labor are: 

1. Rupture of the cyst. 

2. Torsion of the pedicle. 

3. Suppuration of the cyst. 

4. Hemorrhage into the cyst. 

5. Rupture of the uterus and vagina. 

6. Interference with the passage of the foetus and with contrac- 
tion of the uterus in the third stage. 

Very often pregnancy and labor are not affected by the presence 
of an ovarian cyst. 

The diagnosis of the variety of ovarian tumors is only possible to 
a limited degree. The diagnosis between a cystic and solid tumor 
is seldom difficult. Fluctuation and an exploratory puncture will 
demonstrate the presence of fluid. 

It is manifestly impossible to differentiate clinically a unilocular 
from a multilocular cyst. When smooth and regular in outline and 
consistency the cyst is assumed to be unilocular; when nodular and 
irregular in consistency and when of enormous size it is assumed 



468 SPECIAL DIAGNOSIS 

to be iDultilocular. A positive statement can only be made when 
the cyst is opened. 

Dermoid cysts are suspected when a slow-growing tumor, irreg- 
ular in outline and consistency, is observed early in life. 

Papillary cysts are suspected when the new-growths of the ovary 
are bilateral or intraligamentous, when ascites accompanies them, 
and when they are irregular in outline. 

Exploratory puncture of ovarian cysts was at one time universally 
employed, not only as a diagnostic measure, but for the purpose 
of emptying the cyst. The procedure has given way to the more 
satisfactory and equally safe method of exploratory incision. The 
fluid removed by aspirating may be so characteristic as to permit a 
diagnosis not only of the presence of an ovarian cyst, but of the 
particular variety. INIucinous fluid is characteristic of a pseudo- 
mucinous multilocular cyst of the ovary. The serous fluid of an 
ovarian cyst cannot be recognized from that of ascites or hydro- 
nephrosis. 

Contrary to former belief, the chemical and microscopic 
analyses are of no special value in differentiating the serous con- 
tents of ovarian cysts from ascites. The dangers involved in an 
exploratory puncture of a cyst are infection of the contents, punc- 
ture of a bloodvessel followed by alarming hemorrhage, injury 
to adherent coils of bowel, escape of the contents of the cyst into 
the peritoneal cavity, and finally, though rarely, torsion of the 
pedicle. 

Exploratory incision may be regarded as a safer and more satis- 
factory method. The incision is to be made after the usual prepara- 
tion for an abdominal section. 

FATE OP OVARIAN TUMORS. 

1. Parovarian cysts are self-limiting in their growth, and if they 
rupture it is possible that they will never refill. 

2. Ovarian cysts may disappear after rupture and torsion of the 
pedicle, though this is exceptional. 

3. Simple cysts of the ovary are self-limited in their growth, but 
multilocular proliferating cysts are not. According to Olshausen, 
proliferating multilocular cysts will cause death from pressure 
within three years. 



DIAGNOSIS OF DISEASES OF THE OVARY 469 

4. Proliferating cysts of the ovary, cause death by — 

a. Exhaustion due to interference with nutrition, sleep, and 
breathing. 

b. Cystitis and pyelitis. 

c. Pressure on the ureters, causing hydronephrosis, pyonephrosis, 
and uraemia. 

d. Intestinal obstruction. 

e. Suppuration and gangrene of the cyst, 
/. Peritonitis. 

g. Hemorrhage. 

h. Impediment to labor. 



CHAPTEE XXXII. 

THE DIAGNOSIS OF PERITONITIS. 

I. General Peritonitis. 

1. Benign Non-infectious. 

2. Septic. 

Putrid. 
Gonorrhoeal. 

3. Tuberculous. 

4. Carcinomatous. 

II. Pelvic Peritonitis. 

The pelvic peritoneum covers the concave surface of the floor of 
the pelvis. From the anterior abdominal wall it is reflected to the 
fundus of the empty bladder, passing downward and backward to 
the posterior surface of the bladder and reflected on the anterior 
surface of the uterus at about the level of the internal os. It closely 
adheres to the body of the uterus in front and behind and to a point 
about one-half inch below the attachment of the vagina to the cer- 
vix. From this point it is reflected upon the rectum. Between 
the bladder and uterus the peritoneum forms the so-called vesico- 
uterine pouch. Between the uterus and rectum is a much deeper 
and more important pouch, the cul-de-sac of Douglas, which is 
defined as follows : the upper lateral boundaries are the uterosacral 
ligaments, the lower lateral boundaries and the floor are of peri- 
toneum, the anterior boundary is the supravaginal portion of the 
cervix and the upper half-inch of the vagina, and the posterior 
boundary is the rectum and sacrum covered with peritoneum. 

At the sides of the uterus the peritoneum forms two laminae 
running outward and backward to the sides of the pelvis to a point 
immediately in front of the sacroiliac synchondrosis. The laminae 
are closely approximated above, where they envelop the Fallopian 
tubes and are widely separated below by loose connective tissue. 
These folds are known as the broad ligaments. They enclose the 
Fallopian tubes, the parovarium, and an abundance of connective 
(470) 



THE DIAGNOSIS OF PERITONITIS 471 

tissue at the base. The peritoneum is reflected upon the side walls 
of the pelvis. Over the bladder it is readily separated; over the 
uterus it is closely adherent, save at the lower portion, where it can 
easily be stripped from the organ. The upper part of the rectum 
is closely invested with peritoneum; the lower portion is loosely so. 

I. GENERAL PERITONITIS. 

In general peritonitis the entire peritoneum from the diaphragm 
to the floor of the pelvis is involved in the inflammatory process. 

We will here consider the subject from a gynecological stand- 
point. Schroeder speaks of: 

1. Benign non-infectious peritonitis arising from mechanical 
causes, such, for example, as the escaped fluid and papillomata from 
an ovarian cyst. 

There are none of the clinical manifestations of sepsis, and all 
general and local clinical evidences of peritonitis may be wanting. 
In the abdomen there is usually pain, tenderness, and tympany. 

2. Septic peritonitis arises from the invasion of the peritoneum 
by septic micro-organisms. These organisms gain access to the 
peritoneum from infected tubes, ovaries, and pelvic cellular tissue; 
also, from wounds incident to labor and surgical operations. 

In this form there are present the general and local clinical evi- 
dences of septic infection. The pelvis and abdomen are tender to 
pressure; nausea, vomiting, and hiccoughing are usually present; 
the temperature rises, and the pulse becomes rapid, weak, and 
irregular. In a streptococcus infection death almost invariably 
ensues within a week. The general symptoms of septic infection 
are out of proportion to the local evidences. 

Putrid, saprophytic peritonitis due to infection from the bacterium 
coli and anaerobic bacteria forms a clinical picture which varies in 
its general and local signs. 

There may be few or no local manifestations, but a profound 
general intoxication is invariably present. Menges says that pain- 
lessness and fetid odor to the breath are evidences of colon infection. 

Gonorrhoea! peritonitis unquestionably exists, but the cases are 
few. Gushing and Wertheim were first to demonstrate that gono- 
cocci can Uve upon the human peritoneum. Hunner and Harris, of 
Johns Hopkins, recently reported six cases of gonorrhoeal peritonitis. 



472 SPECIAL DIAGNOSIS 

The general symptoms of infection develop quickly and often to 
an alarming degree, but the course is usually brief and the prog- 
nosis is relatively good. 

In all forms of general peritonitis all of the usual signs of peri- 
tonitis may fail, and the diagnosis must be held in abeyance until 
the abdomen is explored. 

Tympany is the earliest and most reliable symptom. Pain can- 
not be relied on; it may be altogether absent. Nausea and vomit- 
ing are rather constant symptoms, though unreliable in making a 
diagnosis. While the temperature is usually elevated it may be 
normal or subnormal, and does not correspond with the extent of 
involvement of the peritoneum. The character of the pulse is a 
more reliable guide to the general condition of the patient than is 
the temperature. 

In direct proportion to the general septic infection the pulse is 
increased in rate and becomes irregular in rhythm and force. 
Unrest and anxiety are depicted upon the face. 

3. Tuberculous Peritonitis. This disease runs an acute or 
chronic course with a low grade of fever. A fluid exudate commonly 
occupies the abdominal cavity. More often the fluid is free, but at 
times it is encysted between adherent coils of bowel. 

Less often the exudate is fibrinous or serofibrinous, resulting in 
a shortening of the mesentery and adhesion of the peritoneal sur- 
faces of the abdominal viscera. Tubercles stud the peritoneal 
surface. 

The diagnosis may be extremely uncertain or impossible without 
an exploratory incision. In the absence of other causes, such as 
puerperal and gonorrhoeal infection, and in the presence of tubercu- 
losis elsewhere in the body, the tuberculous nature of the lesion is 
suspected. 

4. Carcinomatous Peritonitis. Carcinomatous peritonitis aris- 
ing from a cancerous focus in the uterus, tubes, and ovaries may 
give rise to many of the symptoms common to peritonitis. 

It is especially difficult to differentiate a carcinomatous peritonitis 
from a tuberculous peritonitis. The discovery of the primary lesion 
will suggest the diagnosis. 

Even after opening the abdominal cavity the diagnosis may be 
uncertain and require a microscopic examination of an excised 
portion. 



THE DIAGNOSIS OF PERITONITIS 



473 



II. PELVIC PERITONITIS. 

Definition. Part or all of the pelvic peritoneum is involved in 
the inflammatory process. We therefore speak of diffuse and 
localized pelvic peritonitis. When localized various terms are em- 
ployed to designate the location and extent of the lesion. We 
speak of ^perimetritis when the peritoneal covering of the uterus is 
involved; of perisalpingitis and periovaritis when involving the 
peritoneal coverings of the tube and ovary. 

Fig. 189 




\ M. Levator ani,^ 



Three di\dsions of the pelvic cavity, viz., peritoneal, subperitoneal, and subcutaneous. 

(Fehling.) 



Of greater clinical importance is the distinction between a general 
abdominal and pelvic peritonitis and a well-defined pelvic peri- 
tonitis. ' A pelvic peritonitis may be primary or secondary to a 
general abdominal peritonitis — a fact of prime importance in its 
bearing upon the diagnosis and treatment. 

The infection is usually conveyed through the uterus and tubes 
to the peritoneum immediately surrounding these organs. A direct 



474 



SPECIAL DIAGNOSIS 



invasion from the uterus, tubes, rectum, appendix vermiformis, or 
bladder occurs with less frequency. 

It is possible for infection to be conveyed along the mucosa of the 
uterus and tubes to the peritoneum without causing anatomical 
changes in the uterus and tubes, or such changes may be limited to 
portions of the mucosa. 

Likewise, the lymphatic channels may be mere carriers of infec- 
tion without themselves being involved. We are, therefore, not 
justified in concluding that infection has not passed by a given 
route because there are no anatomical evidences of such an event. 

Fig. 190 




Sagittal section of the uterus to show the manner in which the peritoneum is attached. 
A, body of the uterus; A', anterior surface; A", posterior surface; B, neck; C, isthmus; 
1, cavity of the body; 2, os internum ; 3, os externum; 4, posterior fornix; 5, anterior Up of 
cervix; 6, anterior vaginal wall; 7, posterior vaginal wall; 8, vesicouterine septum; 9, wall 
of the bladder; 10, peritoneum; 11, vesicouterine pouch; 12, cul-de-sac of Douglas. (Testut.) 

Etiology. All that has been said of the etiology of endometritis 
will apply to pelvic peritonitis, inasmuch as the infection very often 
primarily attacks the endometrium. Pelvic peritonitis has its start- 
ing point less frequently in an infection of the bowel, bladder, vagina, 
or general peritoneum. Traumatisms of the perineum, cervix, and 
vagina incident to parturition and surgical operations may open the 
way for infection, which is conveyed by the bloodvessels and lym- 
phatics to the peritoneum. The micro-organisms chiefly found in 
the infected peritoneum are those common to endometritis, salpin- 
gitis, and ovaritis — that is, ' the staphylococcus pyogenes albus, 
aureus, and citreus, streptococcus pyogenes, gonococcus, colon 



THE DIAGNOSIS OF PERITONITIS 475 

bacillus, tubercle bacillus, Kleb^-Loeffler bacillus, pneumococcus, 
typhoid bacillus, and actinomycosis. 

We speak clinically of acute and chronic pelvic peritonitis, of 
peritonitic exudates and adhesions. 

1. Acute pelvic peritonitis shows a marked congestion of the 
bloodvessels or a diffuse blush of the peritoneal surface. Clinically, 
this stage is recognized by intense pain and tenderness in the pelvis, 
contraction of the abdominal muscles, tympany, vesical and rectal 
tenesmus, and painful menstruation. The temperature is elevated; 
the pulse is accelerated in proportion to the degree of temperature 
and general intoxication. Vomiting and hiccoughing are often 
present in advanced cases, and the patient lies with both legs flexed 
upon the thighs. 

In the acute stage all examinations and manipulations should be 
restricted as far as possible. It must be borne in mind that acute 
exacerbations of chronic peritonitis will give all the clinical evi- 
dences of a primary acute attack. Upon opening the abdomen, 
however, evidences will be found of previous involvement. Bandl 
says that high fever, great tenderness, and tympany in the pelvic 
regions are sure signs of pelvic peritonitis. It is only after the 
acute stage has subsided that a bimanual examination will make 
sure that the pelvic connective tissue is not diseased and that the 
peritoneum alone is affected. As a rule, the early symptoms must 
be relied upon in making the diagnosis, for in the majority of cases 
no palpable exudations take place. 

2. Chronic pelvic peritonitis usually begins as an acute infection, 
but may be chronic from the beginning. Bandl says: ''The lesion 
can be diagnosed in girls and sterile women when, during the men- 
strual period or at any other time, with or without fever, there 
exist deep-seated pain in the pelvis and more or less tenderness 
over the lower portion of the abdomen. If the symptoms are con- 
fined to one side, as is usually the case, the process is most probably 
present in the form of a perisalpingitis and perioophoritis." In the 
opinion of the author, it is not possible to arrive at any intelligent 
conclusion from the above data as to the existence of chronic pelvic 
peritonitis. Too often mistakes are made by relying upon the com- 
plaints of nervous and ignorant patients. A physical examination 
will alone serve .to differentiate the many possible causes of such 
complaints as are found in the inflammatory involvements, the dis- 



476 SPECIAL DIAGNOSIS 

placements, and the new-formations of the uterus and adnexse. The 
anatomical evidences of chronic pelvic peritonitis are inflammatory 
exudates and adhesions. 

Peritoneal exudates follow closely upon the initial acute stage. 
The exudate is serous, seropurulent, or purulent, and may be found 
to occupy part or all of the pelvic cavity. The most dependent 
portion of the peritoneal cavity is the cul-de-sac of Douglas, and 
into it the peritoneal exudate naturally gravitates. It is possible 
for such an exudate to cause a bulging of the posterior vaginal 
fornix, though this is not the rule unless the underlying cellular 
tissue is involved. In a vaginal examination an exudate in the 
pouch of Douglas is sharply outlined, rounded below, and flat on 
the top. When too abundant to be wholly contained within the cul- 
de-sac, the exudate spreads out upon the posterior surface of the 
uterus, may extend laterally, and has been known to fill the entire 
inlet of the pelvis. The adherent and oftentimes distended intestine 
gives an indefinite outline to the upper border of the exudate. 

The consistency of the exudate is variable. Fluctuation may be 
marked, or the exudate may appear firm by virtue of the surround- 
ing inflammatory infiltration. 

In exceptional cases the exudate is located at the side or in front 
of the uterus. It is difficult to palpate it through the vagina because 
of the high location. Without anaesthesia there is an indefinite 
sense of resistance at the seat of the exudate. Under anaesthesia 
the inflammatory mass may be fairly outlined. Where a fluid 
exudate is encapsulated by adhesions, ''adhesion cysts," it is possible 
to mistake it for a sactosalpinx or an ovarian cyst. 

Peritoneal adhesions may follow a serous or purulent exudate, or 
may develop independent of a fluid exudate. The adhesions may 
involve any part or all of the pelvic peritoneum. They manifest 
great variations in development, from a delicate fibrillar structure 
to dense bands. They are most frequently found about the adnexae 
and behind the uterus. Much less frequently they are found in 
front of the uterus, for the reason that the infection commonly 
travels through the tubes to the peritoneum, and it is unusual for 
the tubes to lie in front of the uterus. 

Gonorrhoea is the most common cause of adhesions, and next in 
point of frequency are the infections following labor and abortion. 
As a result of the adhesions the uterus and adnexa^ are more or less 



THE DIAGNOSIS OF PERITONITIS 



477 



fixed, and their position is altered by contraction of the adhesions. 
With the exception of prolapsus and inversion of the uterus, all 
sorts of malpositions are caused by adhesions about the uterus and 
its appendages. 

The clinical diagnosis rests upon the physical findings. In a 
conjoined examination the adhesions are recognized as cords and 
bands, rarely as a diffuse thickening surrounding the viscera of the 
pelvis and uniting their peritoneal surfaces. 



Fig. 191 




Peritoneal adhesions bind the uterus in retroposition. 



The abnormal fixity of the organs and their displacements are 
suggestive of the presence of adhesions. Not infrequently such 
fixity and displacements are recognized in an examination without 
anaesthesia, and it is presumed that adhesions exist, though they are 
not demonstrated without the administration of an anaesthetic. 

Where displacements of the uterus and adnexce with restricted range 
of motion are associated with tenderness and an indefinite sense of 
resistance at the side of or behind the uterus, an anaesthetic should 



478 SPECIAL DIAGNOSIS 

he administered to determine the ^possible 'presence of adhesions and 
exudates. ^ 

Differential Diagnosis. It is at times extremely difficult to differ- 
entiate a pelvic peritonitis from a hypercesthesia peritonii found in 
women of nervous temperament. The general nervous state of the in- 
dividual, the absence of all causes of infection, and, finally, a conjoined 
examination under anaesthesia will serve to establish the diagnosis. 

A retroflexed gravid uterus may be confounded with a peritonitic 
exudate. The fact of pregnancy should be determined by the usual 
signs. In the first trimester the cessation of menstruation and 
nausea is occasionally simulated by like complaints due to the in- 
flammatory lesion about the uterus in the absence of pregnancy. 
Such exudates are most often found in multiparse in whom the 
changes in the breast are not usually well marked during the early 
months of pregnancy. Of greatest importance are the changes in 
size, form, consistency, and the rate of growth of the uterus. An 
effort to replace the uterus without anaesthesia, or, if this fails, with 
anaesthesia, will determine the presence or absence of adhesions. 

In exceptional cases a uterus fixed by adhesions cannot be distin- 
guished from an incarcerated uterus without an exploratory incision. 
This is particularly true where adhesions bind the uterus loosely to 
such movable structures as the bowel, omentum, and bladder. 

Where the uterus is fixed and tender to pressure adhesions are 
suspected, even though they cannot be felt under anaesthesia. 

A retrouterine hsematocele may organize into peritoneal adhesions 
in the absence of infection. The history and physical evidence of 
an ectopic pregnancy, together with the usual signs of a haematoma 
and the absence of a history of infection, will serve to differentiate 
this condition from true inflammatory peritonitic adhesions. 

Tuberculous peritonitis with encysted fluid, according to H. Dure, 
is differentiated from an ovarian cyst by a family history of tuber- 
culosis, signs of the existence of other tuberculous lesions, a history 
of frequent abortions or of the death of several children from tuber- 
culosis; general symptoms of tuberculosis, such as loss of weight, 
strength, and appetite, evening rise of temperature, night sweats, 
pelvic pains, amenorrhoea, leucorrhoea, and the previous occurrence 
of salpingo-oophoritis. The differential diagnosis of pelvic inflam- 
matory exudates from sactosalpinx and ovarian cysts is referred 
to in the chapters on Diseases of the Tubes and Ovaries. 



CHAPTER XXXIII. 

THE DIAGNOSIS OF PARAMETRITIS (PELVIC CELLULITIS). 

I. Acute Parametritis. 
II. Chronic Parametritis. 

The loose connective tissue of the pelvis lies immediately beneath 
the peritoneum. It surrounds the supravaginal portion of the cer- 
vix, and extends laterally between the layers of the broad ligament 
and along the sides of the pelvis. There is but a small amount of 
connective tissue in front of the uterus beneath the vesicouterine 
fold of peritoneum. Behind the uterus and beneath the uterorectal 
fold of peritoneum is a considerable amount of loose connective 
tissue so intimately connected with the rectum, cervix, and vagina 
that it frequently becomes the seat of infection. 

A knowledge of the location, loose texture, and relation of the 
connective tissue to the neighboring structures will serve as a basis 
for our understanding of pelvic cellulitis. 

Definition. By parametritis is meant an inflammation of the 
cellular tissue of the pelvis. The extent of the lesion varies. While 
sometimes diffuse, it is usually localized. According to the location 
of the lesion we recognize paracystitis, when the limited amount of 
connective tissue about the base of the bladder is involved; para- 
proctitis, when the inflammation is in the cellular tissue about 
the rectum; paravaginitis, when it is about the vagina; posterior 
parametritis, when in the connective tissue lying within the 
uterosacral folds and beneath the floor of the pouch of Douglas, 
and lateral parametritis, when between the layers of the broad 
ligament. 

Classification. Freund classifies parametritis as follows: 

I. Acute Inflammation of the Pelvic Connective Tissue 

WITH OR WITHOUT AbSCESS FORMATION. 

a. Simple phlegmon. 

b. Septic phlegmon. 

(479) 



480 SPECIAL DIAGNOSIS 

II. Chronic Inflammation of the Pelvic Connective 
Tissue. 

a. Circumscribed atrophic. 

b. Diffuse atrophic. 

The causes of pelvic celluUtis are identical with those of pelvic 
peritonitis, and it is the rule that these lesions rarely exist singly. 

I. ACUTE PARAMETRITIS. 

The initial symptoms are, as a rule, less violent than in acute 
pelvic peritonitis. This is particularly true of the pain and tender- 
ness. The effect upon the pulse and temperature may be equally 
severe. 

Fig. 192 



Contraction of the left broad ligament, drawing the uterus in a left lateral position. 

Bandl says: ^'If a day or two after an attack of fever and the 
appearance of the described initial symptoms the uterus is found 
enlarged transversely in the region where the broad ligaments leave 
it, parametritis certainly exists, and it is hardly necessary to prove 
it by bimanual examination. If after fever has lasted for several 
days points of resistance are found over Poupart's ligament corre- 
sponding to the seat of pain and tenderness; or if swellings have 
formed above or extend to the centre of Poupart's ligament, or 



THE DIAGNOSIS OF PARAMETRITIS 481 

internally to the anterior superior spine of the ilium, the convex 
border of which is readily felt or even seen; or if by firm pressure 
on the abdominal wall tumors corresponding to the broad ligament 
are found, then it is also certain that the process involves the para- 
metrium. If still doubtful, the diagnosis may be confirmed by 
vaginal examination, which in most cases will reveal the presence 
of large masses at the sides of the uterus, extending anteriorly or 
laterally to the pelvic wall, or filling one side of the pelvic cavity, 
showing clearly that the swellings felt through the abdominal wall 
are masses of exudate extending below the peritoneum.'* 

In many cases the exudate cannot be felt through the abdominal 
wall, because it lies low in the pelvis and is only to be palpated 
through the vagina. "If with more or less infiammatory symptoms 
masses form in the neighborhood of the cervix, or extend to the 
deeper portions of the pelvis, being doughy and soft at the begin- 
ning, but rapidly becoming harder, or if large, well-defined swellings 
form in the true pelvis, in front of or behind the uterus, the process 
can be none other than phlegmonous inflammation of the cellular 
tissue." 

II. CHRONIC PARAMETRITIS. 

Chronic parametritis is diagnosed from the position and consist- 
ency of the exudate and its relation to neighboring structures. The 
history of the infection, together with the general and local symp- 
toms, can no more than suggest the probable nature of the lesion. 

Position of the Exudate. The exudate occupies the position of 
the pelvic connective tissue and with greatest frequency in localities 
where the connective tissue is most abundant, namely, behind the 
uterus and between the layers of the broad ligaments. In either 
case the exudate lies low in the pelvis. 

When involving the connective tissue at the base of the broad 
ligaments the exudate spreads to the sides of the pelvis. Behind 
the uterus it bulges down into the vagina, forming a rounded, tender 
swelling in the posterior cul-de-sac. When involving the connec- 
tive tissue at the sides of the pelvis, it spreads into a flat mass which 
may or may not connect with the uterus by an elongated exudate 
within the broad ligament. 

It is possible for the exudate to dissect in front and behind in 
the subperitoneal connective tissue of the abdominal wall. It is 

31 



482 



SPECIAL DIAGNOSIS 



impossible for the exudate to burrow to a level above the umbilicus, 
because at this level the subperitoneal connective tissue disappears, 
nor can the dissection go beyond the median line. In this manner 
an abscess may burrow, there being a greater tendency on the part 
of purulent collections to gravitate to a lower level than is the case 
with non-suppurative exudates. The abscess is finally discharged 
through the bladder, vagina, rectum, abdomen, or through one of 
the pelvic foramina. 



Fig. 193 




Perityphlitic adhesions. Uterus and appendages are not involved. 



The form of the exudate varies according to its consistency and 
location. The exudate moulds itself to neighboring structures. 
Beneath the cul-de-sac of Douglas it is somewhat rounded because 
of the limited resistance offered by the surrounding soft structures. 
Between the resisting layers of the broad ligaments the exudate is 
flattened, and the same is true to a greater degree at the sides of 
the pelvis. As the exudate is absorbed its form changes, because 
this removal proceeds irregularly. 

Mobility in the exudate is scarcely perceptible. If attached by 
a broad base to an immovable structure the exudate will be firmly 
fixed. A small exudate within the broad ligament may show some 



THE DIAGNOSIS OF PARAMETRITIS 



483 



degree of mobility, but as a rule we speak of cellular exudates as 
fixed and immovable. 

The consistency is also subject to great variations, depending upon 
the character of the exudate, whether oedematous, fibrinous, or 
purulent. At one time it is soft and fluctuating, and again it is as 
firm as cartilage. In the early development of the exudate the con- 
sistency is elastic and yielding; later it becomes firm from organiza- 
tion and contraction. If suppuration ensues there will be a boggy 
and possibly fluctuating mass. The consistency is best determined 
by rectal and vaginal palpation. 

Tenderness to ^pressure is characteristic of all inflammatory lesions. 
Large exudates may exist with little tenderness, but the tenderness 
is a reliable guide to the inflammatory character of the mass. 

The relation of the exudate to neighboring organs is most impor- 
tant in differentiating from new-formations in the pelvis. The 
exudate blends intimately with adjacent structures and cannot be 
outlined apart from them. In intraligamentous exudates the mass 
lies snugly against the side of the uterus, sometimes surrounding 
the supravaginal portion of the cervix, but never extending to the 
fundus. In paravaginitis it may be impossible to move the vaginal 
mucosa from the exudate. In paraproctitis the exudate may bulge 
into the rectum, narrowing the bowel and so intimately blend with 
the wall of the rectum that it moves as one mass. In the absorption 
of the exudate the periphery is flrst to disappear. In an intraliga- 
mentous exudate the mass may retreat from the side of the pelvis and 
foriii an elongated or rounded swelling firmly adherent to the uterus. 

Differential Diagnosis. The distinction between a perimetric 
and a parametric exudate is at all times difficult. Certain well- 
defined points of distinction serve to differentiate the two lesions, 
but it is to be remembered that they commonly coexist. 



Parametritis. 

1. Exudate lies low in the pelvis. 

2. Pain may not be great, and is dull and 

continuous. 

3. Exudate commonly at the side of the 

uterus, never extending to the fundus. 

4. Exudate of firm consistency; tendency to 

suppuration. 

5. Uterus partially fixed. 

6. Tympanites usually absent. 

7. Facial expression may be natural. 

8. Nausea and vomiting not common. 

9. Oiie leg flexed. 



Pelvic Peritonitis. 

1. Lies high in the pelvis. 

2. Pain usually more intense, sharp, lancin- 

ating and paroxysmal. 

3. Exudate commonly behind the uterus, 

often extending to the fundus. 

4. Commonly less firm; no great tendency to 

suppurate. 

5. Uterus may be firmly fixed. 

6. Tympanites usually present. 

7. Facial expression anxious. 

8. Nausea and vomiting present. 

9. Both legs flexe4f 



484 



SPECIAL DIAGNOSIS 



Retrouterine Parametritis. 

1. Outline rounded below and sharply cir- 

cumscribed. 

2. Exudate cannot extend to fundus. 

3. Uterus may be crowded forward; usually 

only the cervix is crowded forward. 

4. Rectum firmly and closely surrounded by 

exudate in front and at the side. 

5. Mucosa of rectum does not move upon the 

exudate. 

6. Posterior vaginal fornix depressed. 



Retrouterine Perimetritis. 

1. Outline diffuse, not sharply circumscribed. 

2. Exudate may extend above fundus. 

3. Uterus may be crowded forward by the ex- 

udate or drawn backward by adhesions. 

4. Rectum crowded backward by exudate. 

5. Mucosa moves independently of the mass. 

6. Usually not depressed. 



A paratyphlitic exudate is not infrequently confounded with an 
intraligamentous parametritis. It is possible for a paratyphlitic 
exudate to burrow between the layers of the broad ligament to the 
side of the uterus. 



Perityphlitis. 

1. Initial symptoms: nausea, vomiting, con- 

stipation, fever, pain at McBurney's 
point. 

2. Tendency of a parametric abscess is to 

rupture into the bowel and peritoneal 
caxdty. 

3. Tendency to recurrence. 

4. Exudate Ues high on the right side and 

spreads from above downward. 



Parametritis. 

1. Initial symptoms: fever, constipation, 

pain low in the pelvis at the side of the 
uterus, rarely nausea and vomiting. 

2. Little tendency to rupture into the bowel 

and peritoneal cavity. 

3. Tendency to recurrence not so great. 

4. Exudate lies low in the pelvis and spreads 

from below upward. 



A pelvic hsematoma may so closely resemble a parametric exudate 
as to be indistinguishable without an exploratory incision or punc- 
ture. Both lesions are confined to the cellular tissue of the pelvis, 
and in general contour, size, and consistency they may be quite 
similar. The following tabulated points will usually serve to differ- 
entiate the two: 



Pelvic Hsematoma. 

1. Develops suddenly. 

2. History of ectopic pregnancy. 

3. Onset marked by normal or subnormal 

temperature and rapid, feeble pulse. 

4. Exudate usually beside the uterus and 

circumscribed. 

5. Exudate at first doughy, later firm, never 

tender unless infected. 

6. Exploratory punctxire, blood. 



Parametritis. 

1. Develops more gradually. 

2. Absent. 

3. Onset marked by rise of temperature and 

increased pulse rate. 

4. Exudate beside or behind the uterus and 

less circumscribed. 

5. Exudate firmer and tender. 



6. Exploratory puncture 
negative. 



■ serum, pus, or 



Subserous fibroids may be confounded with a parametric exudate. 
When the exudate is round and attached by a broad base to the 
uterus and not especially tender to pressure, the diagnosis is diffi- 
cult, and may not be cleared up without an exploratory incision. 
The difficulty of diagnosis is especially great in intraligamentous 
fibroids. The mor^ movable the mass the more likely it is to be a 



THE DIAGNOSIS OF PARAMETRITIS 485 

fibroid. In a cellular exudate there is a history of infection and 
the mass grows rapidly. In fibroids there is no history of infection, 
and the growth develops slowly. The depth of the uterine cavity 
is increased in case of fibroids beyond that found in parametritis. 
The effects of treatment will aid in the diagnosis; in parametritis 
the mass should diminish under treatment, while in fibroids little 
or no effect will be observed. 

Malignant, diseases of the pelvis, involving the parametrium, may 
arise from a primary focus in any of the pelvic viscera. There is 
absence of a history of infection, no acute onset being experienced, 
and there are present the general symptoms of malignancy rather 
than of infection. The primary seat of malignancy can usually be 
determined, and the hard, irregular character of the infiltrated area 
will serve to indicate the condition. 

Parametritis. Psoas Abscess. 

1. Usually of acute origin. 1. Usually of chronic origin. 

2. Absence of spondylitis. 2. Spondylitis present. 

3. Exudate tender to pressure. 3. Exudate not tender to pressure. 

4. Fluctuation may be absent; induration 4. Fluctuation only occasional; no hard exu- 

about abscess always present. date about abscess. 

5. Thigh flexed, not rotated. 5. Thigh flexed and rotated inward. 

6. Temperature may be high. 6. Temperature absent or slight rise, espe- 

cially in the morning. 

7. Exploratory puncture shows absence of 7. Presence of same. 

tuberculous exudate and tubercle bacilli. 

8. TubercuUn gives no reaction. 8. Tuberculin usually gives a reaction. 



PART III. 

THE DIAGNOSIS OF THE DISEASES OF 
THE URINARY SYSTEM. 



CHAPTEE XXXIV. 

THE DIAGNOSIS OF DISEASES OF THE UEETHKA AND 

BLADDER. 

Anatomy and Physiology. 
Methods of Examination. 

Urethroscopy. 

Cystoscopy. 
Malformations and Diseases of the Urethra. 
Diseases of the Bladder. 

1. Developmental Deformities. 

2 Malpositions and Malformations. 

3. Foreign Bodies. 

4. Vesical Fistulse. 

5. Cystitis. 

6. New-formations. 

WiNCKEL, in his monograph on Diseases of the Female Urethra 
and Bladder, has pointed out that much that is now known 
of the diseases of the urethra and bladder was known hundreds 
and thousands of years ago, and, having been forgotten, was 
rediscovered by late observers. The Cnidian school possessed a 
fairly accurate knowledge of diseases of the bladder, as did the 
Indians 100 B.C. ^tius (502-575 B.C.) described ulcerative affec- 
tions of the bladder, and Paul of iEgina (670 a.d.) treated diseases 
of the bladder by means of injections through a catheter. In the 
nineteenth century Simon advised a series of conical specula with 
obturators, by which the urethra could be dilated to the extreme 

(487) 



488 DIAGNOSIS OF DISEASES OF THE UBINARY SYSTEM 

degree, permitting a digital examination of the bladder. From that 
time to the present methods of examining the urinary tract have 
been rapidly introduced and perfected. We are especially indebted 
to Max Nitze, K. Pawhk, M. Sanger, and Howard Kelly, whose 
contributions to this department of the diseases of women rank 
with the most important of the past century. 

THE ANATOMY AND PHYSIOLOGY OF THE URETHRA AND 

BLADDER. 

Urethra. The average length of the female urethra is one to 
one and a half inches. It runs from below upward and backward 
in a straight or slightly curved line, and its anterior extremity lies 
about four-tenths of an inch below the symphysis. 

The wall of the urethra is about one-fifth of an inch thick, and 
possesses an unusual amount of elastic fibre, which permits a great 
degree of stretching. The epithelium in the lower segment of the 
urethra resembles the stratified epithelium of the vagina, while that 
of the upper segment is like that of the bladder. 

Near the external urethral orifice Skene found two lacunae which 
he regarded as glands. They are known as Skene's ducts. Their 
orifices, which open into the urethral canal, are about one-twentieth 
of an inch in diameter. The ducts are about one-quarter of an 
inch long and run upward along the wall of the urethra. A fine 
probe can be inserted into them for about one inch. 

Numerous smaller lacunae lie along the course of the urethra. 
These are lined with transitional epithelium, the lowermost being 
a single layer of cylindrical epithelium. Higher up it becomes 
stratified cylindrical, and near their mouth it becomes flat pavement. 
In addition to these lacunae there are numerous small mucous glands 
opening into the canal. Beneath the mucosa is the submucosa com- 
posed of an elastic network, and external to this is the muscular 
wall composed of longitudinal and circular muscular fibres. 

The external orifice of the urethra is a vertical oval opening 
one-fifth of an inch long, while the internal orifice is a mere slit. 

Bladder. The empty female bladder lies in the median line 
behind the pubis and in front of the vagina. When the fundus is 
distended it inclines slightly to the right side and may reach to 
the level of the umbilicus. The average capacity is 400 grams, 



DIAGNOSIS OF DISEASES OF URETUBA AND BLADDER 489 

which is somewhat less than that of the male bladder. The mini- 
mum capacity is 20 to 30 grams, and the maximum 3320 grams 
(Fritsch). The bladder wall consists of three layers — peritoneal, 
muscular, and mucous. 

1. The peritoneum covers the fundus of the bladder and is re- 
flected to the anterior surface of the body of the uterus and to the 
anterior abdominal wall. It is loosely adherent to the muscularis. 
When the bladder is greatly distended the peritoneum is so drawn 
upward that a hand's breadth of the bladder not covered with peri- 
toneum presents above the pubis — a fact to be remembered in 
suprapubic operations on the bladder. 

2. The middle layer consists of unstriped muscular fibres arranged 
in three sublayers, namely, an external layer of longitudinal fibres, 
a middle layer of oblique and transverse fibres, and an internal 
layer of longitudinal fibres. 

3. The internal layer — mucosa — is composed of several layers 
of transitional epithelium resting upon a loose connective tissue 
base. Folds or rugse are found over the entire inner surface of the 
bladder, with the exception of the trigone and openings. These 
are due to laxity of the mucosa. In the trigone the mucosa closely 
adheres to the submucosa, and therefore no folds are to be seen. 
Small acinous glands which secrete mucus are distributed in the 
mucous membrane of the fundus and about the internal sphincter. 

The bladder is rich in bloodvessels. A thick, capillary network 
runs beneath the superficial epithelium of the mucous membrane. 
The vertex is not so richly supplied with bloodvessels as the deeper 
parts. The arteries supplying the bladder are the vesicularis 
superior and inferior branches of the arteria hypogastrica. The 
veins empty into the plexus pudenda vesicularis. 

The nerve supply comes from the plexicus hypogastricus inferior 
of the sympathetic system and from the third and fourth sacral 
nerves. 

The bladder has three openings : the internal orifice of the urethra 
arid the two orifices of the ureters, which lie one and one-half inches 
above and to either side of the urethral opening. The ureteral 
openings are separated about one inch and are connected by a 
prominent fold of the mucous membrane known as the ligamentum 
uretericum. The three openings form the angles of a triangle 
known as the trigone. Above the trigone on the posterior wall of 



490 I>IAON0SIS OF DIS:^ASES OF THE URINARY SYSTEM 

the bladder is the has fond, and all the bladder lying above the level 
of the ureteral openings is known as the body or fundus. That 
which will be spoken of as the sphincter vesicae probably consists of 
the folds of mucous membrane at the internal orifice of the urethra. 

Physiology of the Bladder. The ureters and bladder possess 
peristaltic movements by which the urine is forced through the 
ureters into the bladder and from the bladder past the sphincter 
internus. These systolic and diastolic movements of the bladder 
have an important clinical bearing in that rest cannot be given to 
the inflamed bladder without artificial drainage. The anterior wall 
of the empty bladder lies upon the posterior wall. When the urine 
enters the bladder it first gravitates to the side pockets and gradually 
elevates the anterior wall. Before the bladder is distended the walls 
are lax and flat; after distention they become tense and rounded. 

Topography of the Bladder. By the present perfected methods 
of examination it is possible to bring into view and to directly 
treat all lesions of any portion of the bladder; hence the necessity 
of exact means of describing the location and extent of these lesions. 
The following scheme of divisions and subdivisions of the interior 
of the bladder is proposed by Howard Kelly: 

1. The natural landmarks within the bladder. 

2. The relation of the bladder to surrounding structures. 

3. An artificial division into hemispheres and quadrants. 

1. The Natural Landmarks in the Bladder, (a) The internal 
ORIFICE OF THE URETHRA marks the junction of the urethra and 
bladder. 

(6) The ureteral orifices are to be regarded as the most im- 
portant of the landmarks of the bladder. The orifices lie at the 
top or to one side of the so-called ureteral prominences, which are 
truncate cones 5x3 mm. 

(c) Ureteral folds is a name given by Kelly to designate 
rounded elevations sometimes seen in the mucosa stretching back- 
ward and outward from each ureteral opening toward the pelvic 
walls and for a distance of about three-quarters of an inch. They 
are regarded by Kelly as the terminal ends of the ureters as they 
pass through the bladder walls. 

(d) The trigone is a triangular area at the base of the bladder, 
having angles formed by the internal urethral and the two ureteral 
openings; the sides connecting these openings bound the trigone 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 49I 

and are about one inch long at the base and three-quarters of an 
inch long at either side. Many of the lesions of the bladder are 
confined to this area. 

(e) The interureteric ligament connects the ureteral emi- 
nences and is seen as a line sometimes elevated and separating the 
smooth, deeper colored surface of the trigone from the paler surface 
of the bladder. 

(/) Kelly calls attention to the important points relating to the 
FIXED AND movable PORTIONS OF THE BLADDER. As the bladder 
is emptied the upper and more movable portions settle down into 
the lower and more fixed portions like one saucer within another. 

Fig. 194 




Expression of pus from the ducts of Skene's glands. (Kelly.) 



He observes that the location of inflammatory lesions is determined 
somewhat by the movable and fixed areas. Viewing the interior of 
the bladder with a cystoscope, the respiratory movements define the 
movable area as contrasted with the fixed portion. 

The edges where the two saucers meet form three folds, a pos- 
terior and two lateral folds. The apices formed by the meeting of 
these folds are known as the right and left vesical cornua. 

2. Relations of the Bladder to Surrounding Structures. The trigone 
lies in close proximity to the anterior vaginal wall. Above this the 
base of the bladder is in direct apposition to the supravaginal por- 
tion of the cervix. The upper half of the bladder is loosely covered 



492 I>IAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

with peritoneum. The above relations are important in operative 
procedures upon the bladder and surrounding structures. 

3. Artificial Division of the Bladder into Hemispheres and Quad- 
rants. The distended bladder may be regarded as a sphere divided 
into right and left hemispheres. The intersection of sagittal and 
horizontal planes further divides the bladder into quadrants — the 
right upper and lower quadrants and the left upper and lower 
quadrants. 



METHODS OF EXAMINING THE URETHRA AND BLADDER. 

Percussion. 
Palpation. 

Catheter and Sound. 
Inspection (specular). 
Urinalysis. 

1. Percussion. By percussion a bladder distended with fluid 
may be outlined. The area of dulness may extend to the umbilicus. 
The more distended the bladder the more conical the shape. A 
bladder distended with air gives a high-pitched tympanitic note. 

2. Palpation. By palpation many of the lesions of the urethra 
and bladder are detected. 

(a) The urethra is directly palpated along the median line of the 
anterior vaginal wall. In urethritis palpation will be painful in 
proportion to the intensity and extent of the inflammation; the 
urethra may be felt as a firm cord. 

Fissures and caruncles at the urethral orifice are exquisitely sen- 
sitive to pressure. 

By previously dilating the urethra with bougies it is possible to 
insert the finger through the urethra into the bladder for the pur- 
pose of detecting irregularities and foreign growths. 

(6) The bladder when empty is seldom recognized in a bimanual 
examination. In cystitis tenderness and pain are proportionate to 
the intensity and extent of the lesion. In chronic cystitis, and par- 
ticularly in tuberculous cystitis, the thickened bladder wall may be 
distinctly palpated through the vagina. Stone may sometimes be 
palpated and outlined in an abdominovaginal examination. 

Kelly recommends placing the patient in the knee-chest position 
and letting the air distend the vagina, when the fingers of both 



DIAGNOSIS OF DISEASES OF UBETHBA AND BLADDER 493 

hands can be brought close together and the entire bladder be 
distinctly outlined. 

While possible to palpate a portion of the interior of the bladder 
through the dilated urethra, such a procedure is no longer to be 
recommended in view of the more efficient and less objectionable 
method of direct inspection. 

Fig. 195 




The thickened bladder is engaged between the index and middle finger of the left hand 
in the vagina, and the fingers of the right hand over the abdomen. 



3. By Catheter and Sound. By the use of the catheter the 
urine is evacuated from the bladder and can be examined free of 
contamination with products of the urethra and vagina. By the 
catheter foreign bodies, stricture, and fistulse are sometimes detected 
in the urethra and bladder. The sound is a more efficient instru- 
ment for the detection of such conditions. 

4. Inspection. Inspection of the urethra and bladder has been 
made possible by the contributions of Nitze, Casper, Pawlik, Skene, 
Simon, Kelly, and others. In almost all diseases of the urethra 
and bladder it is desirable to make an exact diagnosis by direct 
inspection, 



494 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

The lesions involving the urethral orifice can be recognized by 
direct ocular inspection. Pus seen to ooze from the urethra is, 
with few exceptions, recognized as of gonorrhoeal origin. The 
orifices of Skene can be directly inspected by separating the lips 
with the fingers. By separating the labia and introducing a specu- 
lum direct inspection will disclose a vesicovaginal fistula, 
vesicocele, and tumors of the base of the bladder and 
urethra growing into the vagina. 

Urethroscopy. An endoscope is introduced the entire 
length of the urethra. Light is reflected by a head mirror 
into the urethra as the instrument is withdrawn. The 
mucosa collapses about the end of the urethroscope, form- 
ing a flat funnel which can be directly inspected. By 
virtue of the compression the mucosa is unnaturally pale. 
Polyps, new-growths, foreign bodies, ulcers, and inflamed 
surfaces are thus brought into the field of vision and are 
made accessible to direct treatment. 
Urethral CystOSCOpy. Two mcthods of inspecting the interior 

o fl.1 1 o r3-i^ or 

of the bladder will be described — the Kelly-Pawlik and 
the Nitze. There are numerous modifications of these methods, 
all worthy of consideration were there space to devote to them. 

The Nitze cystoscope is not in general use in the United States, 
preference being given to the direct method of Kelly and Pawlik. 
On the Continent the Nitze and various modifications, such as 
Casper's, are quite generally used. Each has its merits, and is 
deserving of full consideration. 

The following are the advantages of the Nitze cystoscope as com- 
pared with the Kelly-Pawlik: 

1. A general anaesthetic is seldom required. 

2. The lithotomy position is used to the best advantage. 

3. The bladder is more completely dilated with water than 
with air. 

4. The urethra is not widely dilated, hence incontinence of urine 
seldom occurs. 

5. No assistance is required in making the examination. 

6. Less skill and a shorter time are required in making the 
examination. 

Technique. Four conditions are prerequisite to the use of the 
Nitze cystoscope: 



DIAGNOSIS OF DISEASES OF URETHBA AND BLADDER 495 

1. Permeability of the urethra, sufficient to easily permit the 
passage of the cystoscope. This requires a diameter of not less 
than 5 mm. 



Fig. 197 



Fig. 198 




m 




Fig. 197.— Nitze's ureter cystoscope for illuminating the bladder and simultaneous cath- 
eterization of the ureters. 

Fig. 198.— Janet-Frank's bladder phantom. Intended for practising cystoscopy, ureteral 
catheterization, and intravesical operations, 



496 DIAGNOSIS OF DISEASES OF THE UBINABY SYSTEM 

2. A capacity sufficient to retain at least 100 c.c. of fluid. 

3. Power on the part of the sphincter vesicae to retain the fluid. 

4. Transparent fluid. 

1. Permeability. It is essential that the cystoscope should pass 
into the bladder without meeting unusual resistance; otherwise 
the pressure on the mucus glands may smear the lamp with mucous 
secretion and thereby obscure the field of vision. Where an obstruc- 
tion exists in the urethra it must be removed before the cystoscope 
is introduced. Strictures and foreign growths of the urethra are 
uncommon in women. Spasmodic contractions of the sphincter 
vesicae may obstruct the passage of the cystoscope, but this may 
be overcome by slow, continuous pressure and by an anaesthetic. 

2. Capacity of the Bladder. The usual amount of fluid injected 
into the bladder preparatory to making a cystoscopic examination 
is 250 c.c. A capacity of less than 100 c.c. precludes the examina- 
tion, because of imperfect distention of the bladder and the danger 
of overheating the mucous membrane. If irritability of the urethra 
and bladder does not permit the retention of a sufficient amount 
of fluid with which to distend the bladder, it may be possible to 
overcome the irritability by the application of a 2 per cent, solution 
of cocaine to the sphincter vesica?. Injection of the solution into 
the bladder is not regarded as a safe procedure. Where this will 
not overcome the irritability, rest must be enjoined until it has sub- 
sided. In the absence of cystitis the irritability readily reacts to 
the influence of cocaine applied to the urethra. 

Several fatal cases of cocaine poisoning have resulted from injec- 
tion of the solution into the bladder. 

If the indication for a cystoscopic examination is urgent in the 
presence of an irritable bladder and urethra, a general anaesthetic 
may be given. 

The female bladder will not distend so evenly as will the male 
bladder, because of the union of the posterior wall with the cervix 
and vagina, and because of the encroachment of the uterus, adhe- 
sions, pelvic tumors, and other swellings upon the bladder. 

3. Integrity of the Sphincter Vesicae. If for any reason the bladder 
will not retain the urine, the Nitze cystoscope should be discarded 
in favor of the Kelly-Pawlik. 

4. Transparent Medium. The injected fluid must be sterile, non- 
irritating, and transparent. A normal salt solution, sterile water, 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 497 

or, preferably, a saturated solution of boric acid may be used. 
Carbolic acid, bichloride solution, and formalin are too irritating, 
causing an unnatural congestion of the mucosa. 

The hthotomy position is preferred, the patient lying on a high 
table. The urethral opening is cleansed as for the passing of a 
catheter. The urine is then withdrawn through a soft-rubber or 
glass catheter, and without withdrawing the catheter the bladder 
is irrigated with a boric acid or normal salt solution. A fountain 
syringe may be employed, but a piston syringe holding 250 c.c. is 
better. When the injected fluid is returned clear, about 250 c.c. of 
the fluid is left in the bladder preparatory to the introduction of the 
cystoscope. As a rule, the fluid returns clear after two or three 
injections. Where there exists a sediment of mucus, blood, or pus 
several injections may be required, and there are cases in which it 
is impossible to bring about perfect clarity. In such cases the con- 
tained fluid is being continually contaminated by blood and pus 
from the kidneys and ureters. When this is the case it is best to 
slowly inject a small amount of the fluid and to repeat the injection 
before all of the fluid is returned. By taking this precaution the 
sediment at the bottom of the bladder will not be disturbed. It 
sometimes occurs that mucus, pus, and concretions so cling to the 
wall of the bladder that it is impossible to carry out a cystoscopic 
examination. The fluid may appear cloudy because the lamp is 
smeared with mucus in its passage through the urethra. In such 
an event the instrument must be withdrawn and cleansed. 

Cystoscopic Appearance of the Normal Bladder. With the 
bladder moderately distended the surface 0} the mucous membrane 
is smooth. Circumscribed nodular swellings appear late in life and 
are caused by the intersection of muscular bands — the so-called 
trabeculse, which traverse the wall in all directions. Such nodular 
elevations are not to be mistaken for tuberculous nodules. Between 
the trabeculse, which cross one another at all angles, are irregularly 
shaped depressions. These are the forerunners of the pathological 
conditions known as diverticula and hernia. 

The color of the mucosa varies within wide limits. In the normal 
state this variation in color is found not only in different bladders, 
but in various portions of the same bladder. By reflected artificial 
light the normal color is gray or yellowish-rose. The variations 
in color presented at different points in the bladder are accounted 

32 



498 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

for by the relative position of the prism to the field of vision. For 
this reason the shades of color change with the movements of the 
prism. The nearer the prism approaches the surface, the brighter 
the color. As the heat of the lamp warms the contained fluid, the 
mucosa shows a hypersemic reaction. 

The bloodvessels appear as a fine network of veins and arteries; 
the base of the bladder is more vascular than are other portions. 

Fig. 199 




Glass tube with rubber catheter. 



With the exception of the field near the sphincter vesicae, the veins 
are rarely seen in the normal bladder. 

From a clinical point of view the most important parts of the 
bladder are the trigone and base. It is here that foreign bodies and 
pathological lesions are most often observed. The trigone presents 
a smooth, glistening surface, varying in color from gray to dark red, 
and contains a close network of capillaries. 



Fig. 200 




Urethral dilator. 



As the cystoscope is slowly introduced the first image to greet 
the eye is that of the sphincter vesicae, which appears in the upper 
or lower segment of the field of vision, depending upon the respec- 
tive direction of the cystoscope; the image above is the lower seg- 
ment of the sphincter, and vice versa. Pushing the instrument 
forward the image is slowly lost to view. At the base of the bladder 
the tig amentum ureter icum is seen as a ridge of more or less promi- 
nence, running transversely for a distance of about one inch. Turn- 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 499 

ing the instrument slightly to the right or left the ureteral ^prominence 
is seen at the end of the ureteric ligament. The prominence varies 
in size, form, and color. This is often true of the two prominences 

Fig. 201 



Glass graduate, with rubber tube and bulb. 
Fig. 202 



w. R. Grady co. 



Ureteral searcher. 




in the same bladder. The image increases in size and transparency 
as the prism is moved toward the object, decreasing in size and 
becoming darker as the prism is withdrawn. It is important to look 
for small vessels radiating from the ureteral proniinence^ for at the 



500 DIAGNOSIS OF DISEASES OF THE URIJ^ABY SYSTEM 

point from which the vessels radiate the ureteral opening is found. 
It is often possible to see the ureteral openings in the centre or at 
one side of the prominence. 



Fig. 203 



Fig. 204 



Fig. 205 





Fig. 203. — Ureteral catheter, with handle suflBciently reduced to allow speculum to be 
withdrawn after catheter is engaged in ureteral orifice. 
Fig. 204. — Delicate mouse-toothed forceps. 
Fig. 205. — Vesical curette. (Kelly.) 



Difficulty in finding the ureteral opening is experienced when, as 
occasionally happens, the prominence is wanting. When one 
ureteral opening is found, the other is to be sought for at a corre- 
sponding point at the opposite extremity of the ureteric ligament. 
Slight variations in position are sometimes observed. One or both 
ureteral openings may be found close behind the sphincter vesicae, 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 501 

or they may lie some distance beyond the boundaries of the trigone. 
When it is seemingly impossible to discover the position of the 
ureteral openings, it is well to quietly and patiently look for the 

Fig. 206 




Evacuator used for withdrawing residual urine. 



Fig. 207 




Ureteral catheter with rubber tube. 



502 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

ripple of the urine as it is discharged into the bladder from the 
ureters. When the ureteral openings are hidden from view by folds 
of mucous membrane, a greater quantity of fluid may smooth out 
the folds and present the ureteral openings to view. 

Air-bubbles are usually present. It is impossible to avoid intro- 
ducing them, but happily they are no embarrassment in the exam- 
ination. They are round, oval, or hour-glass in form, and move 
together with the contained fluid. 

Fig. 209 




Dorsal position. Elevated pelvis. (Kelly.) 

Movements of the bladder are seen, and are ascribed to the respira- 
tory excursions and to the movements of neighboring structures. 

Salt deposits of a red or grayish-white color are found on the 
surface of the bladder under perfectly normal conditions. They 
are distinguished from pus and tubercles by their color, their sharp 
margins, and by the fact that they are a deposit upon and not an 
infiltration of the mucosa. 

Small cystic elevations, the size of a pinhead, may extend over the 
entire surface of the bladder. They are particularly noticeable near 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 503 

the sphincter vesicse. No pathological significance is to be attached 
to them. 

The Kelly-Pawlik method, when efficiently carried out, is the 
most satisfactory of all methods of cystoscopy. The fundamental' 
principles of a cystoscopic examination as given by Kelly are: 

1. The introduction of a simple cylindrical speculum into the 
bladder. 

Fig. 210 




Introducing searcher into left ureteral orifice. (Kelly.) 

2. The atmospheric distention of the bladder, induced slowly by 
posture. 

3. The illumination and inspection of the vesical mucosa, either 
by means of a direct light, such as a small electric lamp attached 
to the examiner's forehead or to the mouth of the speculum, or by 
means of a strong light reflected by a head mirror. 

The Technique of the Examination. The field of operation, 
the instruments used, and the hands of the operator are to be ster- 



504 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

ilized as for an operation. The bladder and bowel should be emptied 
immediately before the examination. 

Fig. 211 




Bolt table for cystoscopic examination. 



On account of nervousness on the part of the patient or unusual 
irritability of the urethra, chloroform anijesthesia may be chosen if 
not contraindicated. In the majority of cases no anaesthetic is 
required. Kelly recommends the application of a 10 per cent. 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 505 

cocaine solution to the urethra just within the external orifice. 
The application is made on a pledget of cotton wound on a metal 
rod. By this means the urethra can be dilated to the required 
degree without great suffering. 

Fig. 212 




Cystoscopic examination. (Webster.) 



The Posture of the Patient. Kelly recommends the elevated 
dorsal and the knee-chest positions. While the elevated dorsal 
position is the most convenient and least fatiguing to the patient, 
it is not so efficient, because the bladder does not distend so per- 
fectly as in the knee-chest position. 



506 J)IAGNOSIS OF DISEASES OF THE UBINABY SYSTE3I 



Fig. 213 



In the elevated dorsal position the hips are elevated from the 
table eight to twelve inches by firm pillows. The head and thorax 
rest on the table. As a prehminary measure to secure perfect dis- 
tention of the bladder, the patient may assume the knee-chest posi- 
tion and a catheter be introduced into the bladder, through which 
the air may enter. In a minute or two the patient may resume 

the elevated dorsal position, taking 
care that the hips are constantly held 
at a higher level than the abdomen. 
By so doing the weight of the small 
intestines is taken from the bladder, 
and when the urethra is dilated the 
bladder will be perfectly distended. 
The knee-chest position is pre- 
ferred by Kelly, who regards it ap- 
plicable to all cases. When the 
patient can endure the exertion no 
anaesthetic need be given. The pa- 
tient kneels close to the edge of a 
firm table. The hips are kept at 
the greatest elevation, while the 
breast and side of the face lie flat 
upon the table. The small of the 
back curves inward. The knees are 
separated about twelve inches. 
Where an anaesthetic is required 
the body may be supported by an 
apparatus shown in Fig. 209, or by 
an assistant at either side. 

Of immense advantage over the 
dorsal and knee-chest positions is the elevated lithotomy position 
as advocated by Webster in the Journal of the American Medical 
Association, May 17, 1902. During the past three years Webster 
has employed the following method : 

"The patient is placed on a Bolt operating-table in the lithotomy 
position, the ankles being fastened to upright rods, the buttocks 
projecting slightly over the end of the table resting on a rubber 
pad. A steel bar, with two padded supports, is attached to the top 
of the table so as to support the shoulders. After the external 




Hand holding cystoscope in act of intro 
duction. (Kelly.) 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 507 

genitals and vagina are cleansed the patient is enveloped in sterile 
sheets, the urine is withdrawn from the bladder, the urethra is 
dilated to the necessary size, and a speculum containing its obtur- 
ator introduced into the urethra. By means of a crank the top of 
the table is turned on a transverse axis so that the lower end is 
elevated and the upper end depressed. The patient is thus made 

Fig. 214 




Knee-breast position. Cystoscope introduced; sound shows position of anal orifice. (Kelly.) 



to rest on an inclined plane, being held by the shoulder supports, 
her trunk being flat against the table and not bent in any way, 
so that her respiration is free and the anaesthetic easily adminis- 
tered. The table top is usually raised until its lower end is twenty- 
three inches above the normal level. The obturator is then removed 
from the speculum, allowing air to enter and dilate the bladder. 
The examination of the bladder and ureters is then carried out, 



508 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

the examiner standing on a stool so the eyes may be well above the 
outer end of the speculum. 

''This posture has all the advantages of the genupectoral position 
and none of its disadvantages. In difficult cases in which the dis- 
tention of the bladder has not been thoroughly satisfactory I have 
not been able to get better results by trying the genupectoral posi- 
tion." (Webster.) 

Dilating the Urethral Orifice. The dilators are lubricated with 
boroglycerin and introduced into the urethra by a boring motion. 
It is well to first calibrate the urethral orifice in order to select 
the proper size of dilator. The small end of the conical dilator 
is crowded into the urethra until it meets with resistance. The 
index finger is so placed as to mark the point in contact with the 
urethral orifice. The dilator is withdrawn and the index finger is 
found to point to the number of millimetres. Anything below ten 

Fig. 215 




Downes' segregator. 

millimetres will probably require dilating. A dilator slightly less 
in diameter than the calibrator is chosen and larger dilators are 
successively employed until the diameter of the urethra is increased 
to the desired degree. Where the orifice is unusually resistant and 
small, Simon suggests cutting it posteriorly. 

Introduction of the Speculiim. The size of the speculum should 
vary from No. 7 to No. 12, according to the case. When the urethra 
is small and sensitive, No. 7 or No. 8 may best answer the purpose. 
W^ith experience a No. 10 will be satisfactory in the majority of cases. 
The urethral orifice is cleansed with boric acid, an assistant holds 
the labia and buttocks apart, while the operator grasps the specu- 
lum, as shown in Fig. 213, and gently forces it through the urethra 
into the bladder. The obturator is held in place by the thumb 
until the cystoscope has entered the bladder, when it is withdrawn. 
A head mirror reflects the light from an electric drop lamp. 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 509 

The interior of the bladder should be explored systematically, 
moving the speculum from side to side and up and down as the 
occasion requires. 

The Segregator. By this ingenious instrument, first introduced 
by Harris, and modified by Downes, the urine is separately collected 
from each ureter as it passes into the bladder. 

Fig. 216 




Kelly-Pawlik method of cystoscopy. The hips are elevated, the bladder is distended with 
air, the cystoscope is inserted into the bladder, and artificial light is directed through the 
cystoscope into the bladder. 

Two catheters are arranged side by side within a flattened tube, 
each separate and movable on its longitudinal axis. When intro- 
duced into the bladder the catheters are rotated outward on their 
long axes and separated at the bladder end. A metalUc lever 
introduced into the vagina of the female and into the rectum of 
the male provides a water-shed in the bladder, on either side of 
which the urine is collected from the corresponding kidney. The 
urine flows through the catheters into bottles. The application of 



510 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

the segregator is simple and has the great advantage of collecting 
the urine from either kidney separately without catheterizing the 
ureters. However, it has not proven of universal value. 

MALFORMATIONS AND DISEASES OF THE FEMALE URETHRA. 

I. Congenital malformations of the urethra are uncommon. 
They consist of partial or complete absence of the urethra^ atresia, 
displacements, epispadias, and hypospadias. 

1. Partial or complete absence of the urethra may occur in the 
presence or absence of other congenital malformations of the 
genito-urinary tract. All trace of the urethra may be wanting, in 
which case the bladder and vagina may form a single cavity. 

2. Atresia of the urethra as a congenital defect is almost invariably 
associated with malformations of the bladder, vagina, and uterus. 
An outlet for the bladder is commonly found to communicate with 
the vagina or through the patent urachus to the navel. If no such 
communication exists the bladder, ureters, and kidneys will be 
widely distended. 

3. Displacements of the urethra are very uncommon as a congenital 
defect, but are occasionally observed as an acquired one {vide infra). 

4. Epispadias, including a defect in the upper wall of the urethra, 
a division of the clitoris, and a separation of the labia minora, is 
exceedingly uncommon. As associated defects may be mentioned 
separation of the symphysis and an exstrophy of the bladder. 

5. Hypospadias is a defect in the lower wall of the urethra, thereby 
establishing a communication between the urethra and vagina. 

II. Acquired malformations of the urethra are dilatations, 
strictures, diverticula, dislocations, and prolapsus. 

1. Dilatation of the urethra may be confined to any portion of or 
involve all of the urethra. Dilatation of the entire urethra is usually 
the result of coitus or masturbation per urethram; more rarely 
from the presence of a new-growth or foreign bodies. The partial 
incontinence of urine following repeated labors is undoubtedly 
due to injury to the circular fibres of the urethra. Incontinence 
of urine is an almost constant accompaniment. 

Local dilatation of the urethra, known as a urethrocele or diver- 
ticulum, affects the posterior wall of the urethra immediately back 
of the meatus. But few cases are recorded. 



PLATE LVI. 

Fig. 1. Linear Uleer of Bladder Miicosa Magnified. 




Fig. 2. Ulcerated Pateties in the Trigone. Magnified, 



. PLATE LVII. 

Fig. 1. Cystitis originating in the Trigone and extending to 
Adjacent Surfaces. Magnified. 




Fig. 2. Normal Bladder Mvieosa. Magnified. 



DIAGNOSIS OF DISEASES OF UBETHBA AND BLADDER 511 

2. Stricture of the female urethra rs uncommon as compared with 
urethral strictures in men. The causes of these strictures are: 

a. Cicatrization in the anterior vaginal wall following injuries 
through labor. 

h. Chronic urethritis, usually of gonorrhoeal origin, the most 
frequent cause of stricture in the female as well as in the male. 

c. Tumors of the urethral wall which rarely constrict the urethra. 

d. Tumors about the urethra and displaced uteri directly con- 
stricting the urethra. 

e. Cicatrization following a chancre. 

/. Contraction of the urethra without an assignable cause. 

The diagnosis is made from the difficulty and pain experienced 
in urinating and from the character of the flow, which comes in a 
fine stream or in drops. Not only the existence of a stricture, but 
its size, exact location, and the calibre of the urethra are diagnosed 
by calibrating with bougies and by direct inspection through the 
urethroscope. 

3. Dislocations of the urethra may occur in any direction, and 
such dislocations may involve the entire thickness of the urethral 
wall or merely the .mucous membrane. Displacements of the 
urethra are not common, because of the anatomical relations; it 
being a short canal lying immediately underneath the symphysis and 
firmly embedded in connective tissue. Misplacement of the whole 
urethra is the usual occurrence, and is almost invariably secondary 
to a displacement of the bladder, as commonly observed in a vesico- 
cele. Inspection and the use of the sound demonstrate the exact 
position of the urethra. The external orifice is directed forward and 
upward and the internal orifice backward and downward. The 
urethral canal may be so distorted as to render the passing of a 
catheter or sound difficult. Great difiiculty may be experienced in 
voiding the urine. 

The urethra may be elongated and elevated by tumors which 
draw the bladder upward, by extreme distention of the bladder, and 
by the pregnant uterus. 

4. Prolapse of the urethral mucous membrane results but rarely, 
and in patients who have long suffered from dysuria and vesical 
catarrh. Displacements of the uterus and anterior vaginal wall 
are frequent accompaniments. Near the urethral orifice the mucosa 
is loosened and protrudes as a pale-red or bluish, annular, or 



512 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

crescent-shaped fold of mucous membrane. This condition may 
occur at any age, but is more common in girls of a generally 
weakened constitution. 

Urethritis. In the female as in the male, gonorrhoea is the com- 
mon cause of urethritis. In the absence of an established cause for 
urethritis the lesion is assumed to be gonorrhoeal in origin. Long 
after all clinical evidences- of urethritis have disappeared the gono- 
coccus may inhabit the mucosa. Steinschneider examined thirty- 
four cases of recent gonorrhoeal infection, and found the gonococcus 
in the urethra in all of them. 

Sometimes the purulent secretion is seen to exude from the 
urethral orifice, but, as a rule, it is demonstrated by milking the 
urethra. (See Fig. 194.) So characteristic is a purulent discharge 
from the urethra and so seldom is it found in other than gonor- 
rhoeal infection, that it may be regarded as almost conclusive evi- 
dence of the gonorrhoeal nature of the lesion. A cover-slip prep- 
aration of all secretions of the urethra should be made, and at the 
same time of any existing secretions from the cervix. If, as stated 
by Kelly, the gonococcus is found in the secretion of the cervix 
and not in the urethra, complicating urethritis may be assumed 
to be also due to gonorrhoea. Suchanek found in 166 cases both 
the vagina and the urethra affected in 122 and urethral gonor- 
rhoea existing singly in only 3 cases. 

No effort will be made to make a clinical distinction between the 
hypersemic and the inflammatory lesions of the urethra. They are 
dependent upon the same underlying causes and only differ in 
degree. Hence as additional causes which occasionally operate to 
bring about a congested or inflamed urethra may be mentioned 
diseases of the bladder and kidneys which extend to the urethra or 
in which the urine irritates the urethra. The mechanical irritation 
of the catheter and infections acquired by the use of unclean 
catheters are occasional sources. A urethritis sometimes complicates 
the infectious and contagious diseases. The wearing of an ill-fitting 
pessary, the habit of masturbation, and of excessive sexual inter- 
course may result in urethral congestion. 

Urethritis is acute and chronic. 

1. Acute Urethritis. In this stage it is well to limit the local 
examinations as far as possible. Under normal conditions the 
mucous membrane is pale red in color and there is a slight glairy 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 51 3 

secretion. In the acute inflammatory stage the mucosa about the 
urethral orifice appears red and swollen, sensitive to pressure, and 
secretes a variable amount of pus. 

In acute gonorrhoeal infection of the urethra there is at first a 
prickly, burning pain during and immediately following urination. 
Painful and frequent urination are constant symptoms. Three or 
four days later there appears at the urethral orifice a serous, sticky, 
transparent secretion, which by the eighth day becomes greenish 
and purulent, and continues so for about two weeks, when it decreases 
in amount, and by the end of the first month may have entirely 
disappeared. Vivid red points, which mark the mouths of infected 
glands, are often seen about the meatus. The discharge may 
cause an intense itching about the vulva. When it is desired to 
inspect the urethra a 10 per cent, solution of cocaine should be 
applied to the orifice by a swab before introducing the urethroscope. 
Slight bleeding will be caused by the instrument. The congested 
mucous membrane will not appear so reddened because of the 
pressure of the instrument. 

2. Chronic urethritis exists as a diffuse or circumscribed lesion 
easily recognized through the urethroscope. The initial stage may 
be an acute infection, but more often it is chronic from the begin- 
ning. The secretion is limited ; the mucosa is but slightly swollen, 
and is of a livid blue color. There is little or no sensitiveness to 
pressure. 

New-growths of the Urethra. New-growths of the urethra are 
more common in the female than in the male. The following forms 
have been described: 

1. Caruncle. 

2. Fibroma. 

3. Carcinoma. 

4. Sarcoma. 

1. Caruncle. Vascular tumors of the urethra, the so-called carun- 
cles, are most frequent. No age is exempt, but they are more 
common in advanced years. They are located at the urethral 
orifice, sometimes extending into the urethra. They are sessile or 
pedunculated, their form varying from flat and nodulated to pedun- 
culated and crenated. The growth is very vascular, bleeding freely 
to the touch, and is sensitive to pressure. The surface is covered 
with pavement epithelium. In the connective-tissue stroma is an 

33 



514 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

abundant distribution of nerve filaments and capillary bloodvessels, 
this supply of nerves accounting for the great sensitiveness to 
pressure and the pain in urinating. Sexual intercourse becomes 
intolerable, and the suffering racks the constitution. 

The diagnosis can be made by direct inspection. Where doubt 
exists as to the character of the growth a microscopic section of the 
excised tumor should be made. 

2. Fibroma. But few cases are recorded. 

3. Carcinoma of the urethra is rarely primary, but is not infre- 
quently secondary to carcinoma of the vagina, cervix, and vulva. 
I am able to find only twenty-eight cases of primary carcinoma of 
the urethra in literature. The reported cases show a variety of 
anatomical forms: the papillomatous, nodular, smooth, and infil- 
trating, and, finally, the ulcerative. Almost all arose late in life, 
as is common with carcinoma. 

The patient complains of burning and smarting while urinating; 
later there is more or less bleeding. The endoscope should be 
used in all cases when complaint of such symptoms is made. When 
in doubt as to the character of the growth a portion may be excised 
or scraped from the suspected area and submitted to a microscopic 
examination. An interesting case is reported by Percy {American 
Journal of Obstetrics , April, 1903). Percy calls attention to the 
great rarity of the lesion and the possibility of confusing cancer 
with syphilis of the urethra. 

4. Sarcoma. But four cases of primary sarcoma of the urethra 
have been described. One was a myxosarcoma, another a melano- 
sarcoma. 

Urethral Fistula. A fistula of the urethra leading into the vagina 
is a very unusual accident of labor. It is more often artificially 
induced in the treatment of dysuria (Emmet's button-hole opera- 
tion). 

These fistulse seldom assume large proportions, often no larger 
than a pinhead. They are usually located in the floor of the urethra; 
those artificially induced are situated well forward, while those 
caused by labor are usually found near the sphincter vesicse, and 
may involve part of the bladder. 

Foreign bodies in the mrethra are rarely found. They are intro- 
duced from without in masturbating or in the passage of sounds and 
catheters, or a vesical stone may lodge in the urethra, 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 51 5 

The diagnosis is based upon the complaints of frequent, painful 
urination, the presence of pus, blood, and mucus in alkaline urine, 
and the finding of the foreign body by palpating the course of the 
urethra through the vagina, by sounding the urethra, and by means 
of the urethroscope. 

Calculi in the urethra are almost invariably composed of phos- 
phates. 

DISEASES OF THE BLADDER. 

The vesical diseases of women differ materially from those of 
men, and are deserving of special consideration. We will consider: 

1. Developmental deformities. 

2. Malpositions and malformations. 

3. Foreign bodies. 

4. Traumatisms. 

5. Inflammations. 

6. New-formations. 

1. DEVELOPMENTAL DEFORMITIES. 

(a) Vesical fissures (exstrophy) are the most frequent and impor- 
tant of the congenital deformities of the bladder. It depends upon 
a deficiency of the anterior wall, and is mostly associated with 
developmental defects in the genital organs. Various grades of 
this maldevelopment are observed. It may consist of a simple 
cleft of the most dependent portion of the bladder or is less fre- 
quently located near the umbilicus. In the other extreme may be 
found an absence of the entire anterior wall of the bladder. A 
corresponding portion of the abdominal wall is cleft, and the gap 
is filled with a swollen, red, mucous membrane continuous with 
the external skin. The pubic bones are separated one-half to 
three inches and are connected by a fibrous band. The urethra 
is usually wholly wanting and not infrequently the clitoris is 
bifurcated. It is possible for the vagina and uterus to be divided 
by a septum, or for two separate vaginae and a bicornate uterus 
to exist in connection with the fissured bladder. At times the 
posterior wall of the bladder inverts through the abdominal fissure. 
According to Voss, a distended bladder in the foetus accounts for 
these deformities. The distended bladder forces the horizontal 



516 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

rami of the pubes apart, then ruptures and estabUshes a communi- 
cation between the bladder and the abdominal cleft. 

The diagnosis is based upon direct inspection of the protruding 
bladder. The red mucous membrane of the bladder is sensitive 
to the touch, the ureteral openings may be visible, and urine may 
be seen dribbling from the ureters. The lower margin of the 
fissure is reddened, eroded, and burns and itches from irritating 
urine. 

As to frequency of occurrence, Winckel reports two observed 
cases, and Sickel found two cases in 12,689 newborn children. 

(6) Double bladder is due to a failure of the two parts of the 
allantois to fuse in early fetal life. But few cases are recorded. 

(c) Loculate Bladder. Projections are sometimes seen on the 
outer surface of the bladder formed by diverticuli of the bladder 
wall. They are congenital defects, and are not to be confounded 
with diverticuli of inflammatory origin. They have been mistaken 
for supernumerary bladders. 

2. MALPOSITIONS AND MALFORMATIONS OF THE BLADDER. 

The female bladder is subject to malpositions and malformations 
to a far greater degree than is that of the male. 

The normal position of the bladder is in the median line. In 
moderate distention the greatest diameter is transverse, and in 
extreme distention the greatest diameter is the vertical. The 
distended bladder may incline considerably to the right or left of 
the median line and may reach the level of the umbilicus. The 
author recalls seeing in Vienna a post-mortem examination of a 
patient in whom the bladder had been opened and stitched to the 
abdominal wall in the right lower quadrant of the abdomen. The 
bladder, which was greatly distended, lay to one side of the median 
line, and was thought to be a broad ligament cyst. The mistake 
was discovered in the post-mortem examination. 

Elevation of the bladder occurs when the pelvis is filled with a 
tumor mass and when the uterus greatly enlarges and extends into 
the abdominal cavity, dragging the bladder with it even to the 
level of the umbilicus. When the elevated bladder is partly filled 
with urirle it forms a protruding, fluctuating swelling in front of 
the tumor. 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 51 7 

Downward displacement of the bladder (cystocele) is the most 
frequent malposition, and is the result of injury to the pelvic floor 
and of an increase in intra-abdominal pressure. It is most unusual 
for a cystocele to exist in a nullipara. Occupations which involve 
much standing and lifting predispose to cystocele, even in nulliparae. 

In slight degrees of descent the lower part of the bladder is 
somewhat sunken, and in extreme cases the bladder becomes shaped 
like an hour-glass, being divided into an upper and lower part by 
the urethra. In extreme grades associated with prolapsus uteri, 
the urethra may run vertically, the external orifice pointing directly 
upward. Virchow, Philips, Braiin, and others have observed 
dilated ureters and hydronephrosis as the result of obstruction to 
the flow of urine through the stretched and twisted ureters. 

The diagnosis is largely based upon the physical findings; the 
complaints of the patient will give but little clue to the diagnosis. 
There is a frequent desire to urinate, and this is associated with 
more or less pain. Advanced cases may continue with little or no 
disturbance of the bladder functions. A number of cases of cysto- 
cele have been reported in which the passage of the child was 
impeded. The patient, when she is first aware of the protruding 
vaginal wall, regards it as *' falling of the womb." 

With the patient in the lithotomy position the labia are separated 
and she is instructed to bear down. The anterior vaginal wall 
suddenly bulges into a rounded mass, which, if filled with urine, 
will fluctuate when grasped by the fingers. A metallic sound 
placed in the bladder will demonstrate the pouching of the bladder 
into the vaginal tumor. 

When a cystocele is observed the examination is not complete 
until the position of the uterus, the conditions of the pelvic floor, 
and the urine are carefully determined, because malpositions of the 
uterus, injuries to the pelvic floor, and chronic cystitis are almost 
constantly associated with cystocele. 

Eversion of the bladder through a dilated urethra is rarely 
observed. Before such an event can occur there must be a relaxed 
bladder wall and a dilated urethra, which, together with an increase 
in the abdominal pressure, may produce the condition. A sound 
passed through the urethra will demonstrate the absence of the 
bladder. Reducing the protruding mass, the bladder is restored to 
its normal position. 



518 DIAGNOSIS OF DISEASES OF THE UBINABY SYSTEM 

Hernia of the bladder through the inguinal or femoral rings 
and through the foramen ovale has been observed. 

3. FOREIGN BODIES IN THE BLADDER. 

Winckel divides the foreign bodies found in the bladder into 
those that originate in the organ itself, those that come from other 
parts of the body, and those that are introduced from without. 

(a) Foreign bodies originating in the bladder are in large part 
vesical calculi. Calculi may arise from a precipitation of urinary 
salts independent of the previous existence of a foreign body, or 
they may have as nuclei certain foreign elements introduced into 
the bladder from without or from the upper urinary tract. They 
are not so common in the female as in the male, because of the 
shortness of the urethra, the rarity of urethral strictures, and the 
readiness with which lesions of the female bladder are cured. 

In 1792 cases of vesical calculi found in Moscow by Dr. Klein, 
only four occurred in women. In 10,000 women examined by 
Winckel from 1860 to 1884, only once did he find calculi in a woman. 
In 3500 autopsies done upon women in the Dresden City Hospital, 
stone in the bladder was found six times. These statistics speak 
for the infrequency of vesical calculi in women. 

The calculi are usually lodged in the fundus immediately back of 
the trigone. Not infrequently they lie in the pouch of a cystocele. 

In the only case observed by the author a cystocele was filled 
with about twenty stones varying in size up to that of a hickory- 
nut. These were found in a woman, aged sixty-five years. A 
fistulous communication had developed in the cystocele, and through 
it the stones were extracted. 

The stones vary in number, size, color, consistency, and com- 
position. They have been known to be as large as a child's head. 
Hugenberger removed one weighing three and one-half pounds. 
Hundreds of stones may be present at one time in the bladder. 
They are composed of phosphates, urates, oxalates, and rarely of 
cystin. 

(6) Foreign bodies in the bladder that originate from other 
parts of the body are the oxalic and uric acid calculi coming from 
the kidney, the contents of ovarian cysts which have ruptured into 
the bladder (teeth from dermoid cysts have formed the nucleus of 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 519 

stone), the products of extrauterine pregnancy following rupture 
of the gestation sac into the bladder, fecal matter from an ulcerated 
bowel, and echinococci. 

(c) Foreign bodies in the bladder introduced from without are 
portions of catheters, sutures, hairpins, pessaries which have ulcer- 
ated through the vesicovaginal septum, toothpicks, and the like. 

The diagnosis of foreign bodies in the bladder is based upon the 
patient's complaint of an irritable bladder; later, on the clinical 
evidences of cystitis, and, finally and conclusively, upon the finding 
of a foreign body within the bladder by palpation and inspection, 
or upon the spontaneous expulsion of the body. 

If the body is large it may be palpated through the vagina. A 
sound passed into the bladder will often disclose the presence of a 
foreign body. By inspection of the interior of the bladder not only 
the presence of a foreign body is determined, but also the character, 
number, size, form, and exact location. Direct inspection is of 
special value where the stone lies in a diverticulum beyond the 
reach of the sound. Fine gravel, too fine to be detected by the 
sound, is also demonstrated by the cystoscope. Not only the pres- 
ence of a foreign body, but the accompanying cystitis is recognized 
by the aid of the cystoscope. Irritation of the bladder by the for- 
eign body may render the viscus too sensitive for a cystoscopic 
examination without general ansesthesia. 

4. VESICAL FISTUL-ffi. 

By means of a fistula a communication is established between 
the bladder and the vagina, uterus, or intestine. 

(a) A vesicovaginal fistula is most often the result of trauma- 
tism during labor. Protracted parturition, in which the head firmly 
presses upon the vesicovaginal septum, destroys the vitality of the 
tissues and leads to a sloughing, with the formation of a permanent 
fistulous communication between the vagina and bladder. I have 
at the present writing a case under observation in which the vesico- 
vaginal fistula was caused by direct violence during the attempted 
delivery of a child. It is seldom, however, that fistulse are caused 
by direct violence in the use of forceps. More often, as Kelly 
puts it, ''they are due not to the use of forceps, but to the too long 
delay in using them." 



620 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

Carcinomatous invasion of the vesicovaginal septum is second in 
point of frequency. Other causes are vesical calculi, injuries sus- 
tained in vaginal operations, and ulceration from the pressure of 
an ill-fitting pessary. Forced catheterization during labor may 
perforate the bladder. Finally, pelvic abscesses may perforate both 
into the bladder and vagina, thereby forming a vesicovaginal fistula. 

The diagnosis of vesicovaginal fistula is made by the history of a 
possible cause, the complaint of incontinence of urine with its dis- 
agreeable consequences, and, finally, by direct inspection. 

Fig. 217 




Vesicovaginal fistula. A communication is established between the base of the bladder and 
the vagina at a midpoint in the anterior wall of the vagina. 

It is unusual for a fistula developing after labor to manifest itself 
before the end of the first week, though it is possible for urine to 
escape through the vesicovaginal septum during labor. 

The symptoms are quite characteristic. Before the urine escapes 
through a fistula there are usually symptoms of cystitis, bloody 
urine, and rise of temperature. A foul-smelling vaginal discharge 
indicates the sloughing of the vaginal wall, and this is soon fol- 
lowed by a dribbling of urine into the vagina. The vagina, vulva, 
perineum, and inner aspect of the thighs soon show the irritating 
effect of the urine in the form of vulvovaginitis and local dermatitis. 
The distress and inconvenience of the dribbling lowers the vitality 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 521 

of the patient, and she may become extremely weak and emaciated. 
Such individuals are almost invariably sterile. Menstruation may 
be absent, irregular, or painful, but may also be perfectly normal. 
When the fistula is high up and small, the disturbance may be 
slight and the general health unimpaired. 

Difficulty in voiding urine, following labor, should always suggest 
the possible development of a urinary fistula. Under such circum- 
stances it is well to avoid vigorous manipulation for fear of creating 
or extending a fistula in tissue already devitalized. 

Fig. 218 




Vesicouterine fistula. A communication is established between the fundus of the bladder 
and the uterus at about the level of the internal os. 



Palpation of the fistula seldom affords satisfactory information 
when the tissues about the fistula are soft and necrotic. This is 
particularly true of a small opening. In long-standing cases the 
puckered scar tissue and an opening possibly filled with soft mucous 
membrane may often be recognized. 

A sound placed in the bladder and the index finger of the oppo- 
site hand in the vagina may be brought together through a fistulous 
opening. 

Inspection will give positive information as to the location and 
size of the fistula. A Sims speculum introduced into the vagina 
will expose the fistula if large enough. Sterilized milk or some 



522 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

colored aseptic fluid injected into the bladder may be seen to flow 
through the fistula. The cystoscope will expose the opening from 
the vesical side and at the same time afford information respecting 
the condition of the bladder — whether cystitis exists and foreign 
bodies lie within. 

Having established the diagnosis of vesicovaginal fistula, it 
becomes important to consider the nature of its borders, their 
fixation, tension, and the possible existence of other fistulse. 



Fig. 219 




Cervicovesicovaginal fistula. A communication is established between the cervical canal, 

vagina, and bladder. 

(b) Vesicouterine Fistula. When a laceration of the cervix 
extends into the lower uterine segment and the adherent bladder, 
it is possible for healing to be complete in the lower portion of the 
wound, leaving a fistulous opening above between the uterus and 
bladder. 

The urine may be discharged in part through the cervix and in 
part through the urethra, depending upon the size of the fistulous 
opening and the position of the patient. To demonstrate a com- 
munication of the bladder with the uterus, inject sterile milk or 
sterile colored fluid into the bladder and observe through a speculum 
that the fluid escapes from the cervix. To demonstrate that it is 
not a ureterouterine fistula observe that the flow of urine from 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 523 

the cervix is not intermittent. Catheterizing the ureters will demon- 
strate them to be intact. 

(c) Vesicocervical Fistula. Likewise in extensive lacerations of 
the cervix involving the supravaginal portion and the base of the 
bladder a fistulous communication between the cervical canal and 
the blacfder may persist. Such fistulse are demonstrated in a 
manner similar to that indicated in vesicouterine fistula. 

5. CYSTITIS. 

Cystitis is an inflammatory lesion of the bladder due to invasion 
of the walls of the bladder by pathogenic micro-organisms. 

Etiology. In 2500 post-mortem examinations of women, cystitis 
was found sixty-eight times (2.7 per cent.). 

Virchow holds that the urine must first become ammoniacal, and 
by its irritating effects cause the epithelium to become loosened 
before bacteria can gain a lodgement in the bladder wall. Under 
apparently normal conditions the urine may contain bacteria, hence 
there must exist a predisposing cause for cystitis before the bacteria 
manifest their pathogenic properties. 

As predisposing causes of cystitis may be mentioned congestion 
due to overdistention of the bladder, the presence of foreign bodies 
in the bladder, structures crowding upon the bladder from with- 
out (displaced uteri, pelvic exudates, and tumors), traumatisms 
sustained in labor and surgical operations, the passage of catheters 
and sounds, ill-fitting pessaries, the irritating influence of internal 
remedies, of fluids injected into the bladder, and of toxins developed 
within the body in the course of infectious diseases and intestinal 
disturbances. Congestion of the bladder from any of the above- 
named causes will prepare the tissues for invasion by pathogenic 
micro-organisms. 

The micro-organisms found in the inflamed bladder are the 
staphylococcus pyogenes aureus, albus, and citreus; streptococcus 
pyogenes, bacillus coli communis, gonococcus, bacillus tuberculosis, 
bacillus typhosis, and numerous micro-organisms of lesser clinical 
importance, as, for example, the bacillus aerogenes capsulatus of 
Welch, diplococcus pyogenes urese, coccobacillus, and the urobacillus 
liquefaciens. 

Not infrequently two or more of the above-named bacteria are 



524 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

found in the same case. There is a condition known as bacteriuria, 
in which the urine swarms with bacteria in the absence of any con- 
siderable amount of pus or other foreign elements. 

The avenues by which these micro-organisms enter the bladder 
are: 

1. The urethra, the most common of all. Micro-6rganisms 
which always exist in large numbers in the urethra, vagina, and 
vulva may be carried by instruments through the urethra into 
the bladder. It is possible for bacteria to pass through the urethra 
into the bladder without the introduction of instruments. This is 
notably true of the gonococcus. 

2. The kidney, when infected, may involve the bladder through 
the medium of the urine. It has been demonstrated that the urine 
may convey pathogenic micro-organisms to the bladder, and there 
cause an infection without deranging the kidney. 

The colon bacillus and tubercle bacillus probably most often gain 
access to the bladder from the blood by way of the kidney. 

3. The bowel, when adherent to the bladder, may transmit the 
colon bacillus and other micro-organisms to the viscus. 

4. Inflammatory areas surrounding the bladder and intimately 
connected with it may be the sources of infection, as, for example, 
pelvic abscesses, suppurating dermoid cysts, pyosalpinx, and 
perityphlitic abscesses. 

5. Hematogenous infection of the bladder is an infrequent mode, 
though fully demonstrated. 

The following summary is from Kelly: 

1. Cystitis is always caused by the presence of bacteria. 

2. The mere presence of bacteria is not sufficient to cause a 
cystitis; a further predisposing cause is necessary. 

3. There are various modes of entrance for bacteria: through 
the urethra, through the ureter from the kidney directly, from 
inflammatory areas in the uterus or Fallopian tubes, and probably 
from the rectum under similar conditions; still another probable 
avenue of entrance is through the blood. 

4. Under favorable conditions any pathogenic organism may 
give rise to cystitis. 

Anatomical Diagnosis. With the exception of the tubercle 
bacillus the anatomical changes do not differ essentially in the 
various kinds of infections. 



DIAGNOSIS OF DISEASES OF UBETHBA AND BLADDER 525 

Kelly classifies cystitis as diffuse,' circumscribed, and scattered, 
and calls attention to the important and often overlooked fact that 
cystitis is not always a disease of the entire mucosa of the bladder, 
but is more often found in patches with normal mucous membrane 
intervening. This fact speaks for the efficacy of direct applications 
to the involved areas rather than to the entire surface by injections. 

Both acute and chronic lesions are recognized. 

In acute cystitis the bloodvessels are prominent, causing a swelling 
and reddening of the mucosa; small hemorrhages are frequently seen. 

In the chronic stage the reddening is less intense; the mucosa 
appears grayish and is thrown into folds. Papillomatous eleva- 
tions may appear on the surface, and over the surface may be a 
deposit of pus, degenerated epithelium, micro-organisms, and salts, 
forming a false membrane which adheres rather firmly to the mucosa. 

In cases of long standing the muscular wall of the bladder may 
be involved, being greatly thickened and giving rise to trabeculse 
of muscle bundles intersecting at various angles. Abscesses may 
develop in the wall, and superficial ulcers are not infrequently seen 
on the mucosa. The entire mucous membrane may be thrown 
off in the so-called exfoliative cystitis. (See Plates LVI. and 
LVII.) 

Clinical Diagnosis. Frequent painful urination characterizes 
cystitis. The voiding of urine affords very little relief in the marked 
cases. The patient may suffer from a constant desire to urinate. 
The amount of urine voided may be no more than a few drops, 
and this may be passed every few minutes. It is possible for cystitis 
with marked changes to exist in the bladder wall without seriously 
disturbing the functions of the bladder. The temperature and 
pulse are seldom influenced unless the urethra or kidneys are 
involved. The bladder is tender to pressure, and an attempt to 
catheterize or to pass the sound into it causes suffering and should 
not be done without local or general anaesthesia. 

The diagnosis is made from a history of the above symptoms, 
from an examination of the urine, and from direct inspection. The 
urine is usually alkaline in reaction, though sometimes acid, and 
contains albumin, pus, bladder epithelium, crystals of triple phos- 
phates, a variety of micro-organisms, membranous shreds, and 
occasionally some blood. When the bacteria are found in pure 
culture or vastly predorninating over other forms they are the 



526 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

probable cause of the infection. The presence of the gonococcus or 
the tubercle bacillus in the urine is conclusive evidence of the true 
underlying cause. 

The clinical distinction between the acute and chronic forms of 
cystitis is in the duration and intensity of the symptoms. They 
are dependent upon the same underlying causes. 

The cystoscopic diagnosis of cystitis is often difficult and may be 
impossible, but, as a rule, the results are readily obtained and are 
conclusive. In acute cystitis the difficulty arises from the pain 
caused by the manipulation of the instrument. Unless the indica- 
tion is urgent no cystoscopic examination should be made, and then 
only under anaesthesia. 

Local anaesthesia at the neck of the bladder may suffice. When 
possible to delay the examination the patient should be confined to 
her bed, and sitz baths, diluent drinks, and sedatives administered. 
Chronic cystitis may present equally great difficulties because of 
the contracted bladder and the deposit upon the bladder wall. 

Acute cystitis is recognized through the cystoscope by the promi- 
nence of the bloodvessels in the mucosa. This congestion of the 
mucosa presents a variable shade of red, having an irregular dis- 
tribution over the surface. The more acute the inflammation the 
deeper the color. Hemorrhages into the mucous membrane are seen 
varying in size from a pinhead to a pea, and in color from bright 
red to almost black. They are most often located near the mouths 
of the ureters, but may be found at any point in the mucous surface. 

Chronic cystitis presents a paler surface of a grayish color; the 
bloodvessels are faintly traceable ; hemorrhagic areas are darker 
and smaller than in the acute stage. The surface has lost its lustre 
and presents an irregular appearance. The folding and swelling 
of the mucous membrane may hide the mouths of the ureters, and 
be so enormous as to suggest the possible presence of a new-growth. 

There may be no secretion, and, again, the secretion may be 
so abundant and tenacious as to resist all efforts at removal by 
irrigating. Accumulations of the secretion may be mistaken for 
new-growths. Trabeculse and diverticula are often seen in cystitis, 
and are largely confined to the inflamed areas. 

Tuberculous Cystitis. It is not sufficient to merely diagnose 
cystitis and to distinguish between the acute and the chronic forms, 
but it is of the greatest importance to recognize, as far as the present 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 527 

methods of examinations will permit, the bacteriological factors 
involved. This is particularly true of gonorrhoeal and tuberculous 
cystitis, since the organisms causing these lesions are well known 
and we are in possession of the means of detecting them. 

Tuberculosis of the bladder is caused by infection through the 
blood, by extension of a tuberculous process from the kidney, the 
genital organs, or peritoneum. The lesion is more often found in 
early and middle life, and is more frequent in the male than in the 
female. It may be the primary infection in the bladder, or other 
micro-organisms may have previously invaded the bladder. A 
mixed infection is common. In tuberculosis of the kidney it is 
possible for tubercle bacilli to pass through the bladder in the 
urine for years without infecting the bladder. As in other forms of 
infection, the healthy, intact mucous membrane resists the invasion 
of the micro-organisms. 

The ureteral openings and the trigone are the most common seats 
of tuberculosis. Grayish tubercles are seen to stud the mucous 
surface, and are usually in groups. Later the tubercles coalesce 
and form cheesy masses, which in turn break down into lenticular 
ulcers with a flat base and sharp, undermined, ragged borders 
within which small tubercles are seen. The ulcers may perforate 
the bladder wall and form fistulous tracts leading to the para- 
vesicular tissue, rectum, and vagina. 

The diagnosis is based upon the clinical evidences of cystitis, 
associated with the presence of tuberculosis elsewhere in the body, 
particularly in the kidney, upon the bacteriological examination of 
the urine, the cystoscopic appearance of the bladder, the micro- 
scopic examination of excised pieces and scrapings removed from 
the bladder through the cystoscope or a fistulous opening, and 
upon inoculation experiments. Unimpaired general health does not 
exclude the possible presence of tuberculosis. Renal tuberculosis 
may closely resemble vesical tuberculosis. Only by microscopic 
examination and inoculation experiments with catheterized speci- 
mens of urine is it possible to exclude renal tuberculosis. Careful 
and repeated examinations may be required. 

Hypersemia of the Bladder. Hypersemia, irritable bladder, and 
neuralgia are terms in common usage, and imply a disturbance of 
the bladder functions with vascular congestion of the mucosa. This 
hypersemia may be diffuse, but is more often confined to a definite 



528 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

portion of the bladder, particularly to the trigone. The involved 
areas are red, swollen, and tender to the touch of an instrument. 
There is no possible way of distinguishing such a condition from a 
mild, locahzed cystitis. The symptoms are identical. Hypergemia 
of the bladder should be diagnosed without difficulty by a cysto- 
scopic examination. 

6. NEW-FORMATIONS OF THE BLADDER. 

Tumors of the bladder are more rarely found in the female than 
in the male. Nearly every variety of tumor, both benign and 
malignant, is found in the bladder. Of the benign tumors there 
are myoma, fibroma, papilloma, adenoma, and dermoid cysts, and 
of the malignant tumors carcinoma and sarcoma. 

Fere has shown the places of predilection of tumors in a table 
constructed from the reports of 107 cases. In the 107 reported 
cases, 25 were found in the base of the bladder, 17 in the posterior 
wall, 13 in both the base and walls, 8 close to the left ureter, 5 
near the right ureter, 2 in the anterior wall, 1 in the anterior and 
superior wall, 12 were multiple, and 8 diffuse. 

More than half the tumors of the bladder are single. 

Myoma originates from the muscular wall of the bladder, and is 
composed of smooth muscular fibre and a limited amount of con- 
nective tissue. The tumor is sessile or pedunculated. But few 
cases are reported. 

Fibroma usually appears as a fibrous polyp with a long, slender 
pedicle. The tumor is composed of fibrous tissue. They are rare. 

Papilloma of a benign character protrudes into the cavity of the 
bladder as a wart-like growth, with villous projections on the sur- 
face of the tumor. In the place of villosities, there may be nodular 
projections. They are vascular, bleeding freely to the touch. A 
single tuft may be found on the trigone, or the entire inner surface 
of the bladder may be covered. Its growth may be slow, extending 
over years, with but little increase in size. The tumor is rarely as 
large as a child's fist, and is to be regarded as the most common of 
the tumors of the bladder. 

Adenoma of the bladder is a rare new-formation of epithelial 
origin. It is sessile or pedunculated, and seldom attains a large 
§iz^. The histogenesis of the growth is uncertain 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 529 

Dermoid cysts of the bladder have been recorded by Paget and 
Boucher. Their existence has been questioned. Cases are not 
wanting in which a dermoid cyst of the ovary has discharged its 
contents into the bladder and there formed a nucleus for vesical 
calculi. 

Carcinoma of the bladder is primary or secondary. In secondary 
carcinoma the primary seat of the lesion is usually in the cervix, 
having spread thence to the bladder by continuity of tissue. It 
exists as a vegetating villous growth or as a diffuse infiltration, and 
is usually multiple. It bleeds freely to the touch and is exceedingly 
friable. Ulceration quickly follows upon infiltration, and there is 
a peculiar tendency on the part of the growth to remain localized 
for a surprisingly long time. Secondary growths are frequently 
found near the primary lesion. 

Sarcoma appears in the female bladder more frequently than in 
the male, and is found at any period of life from childhood to the 
postclimacteric period. These growths are said to be prone to 
extend through the urethra and to appear at the vulva. 

The diagnosis of tumors of the bladder is determined by palpation 
and inspection. The clinical signs in the early stage are about the 
same, whatever the character of the growth. All show more or 
less tendency to bleed. Hemorrhage is the most characteristic 
symptom. The bleeding is increased during the period of men- 
strual congestion, and has been observed to be greatest in the night. 
Pain may be present in the benign as well as in the malignant 
growths, though seldom to so great a degree, but is strangely absent 
in many cases. Late in the course of the lesion emaciation and 
cachexia develop in cases of malignant growths, and serve to dis- 
tinguish these from benign new-formations. 

Examination of the urine is of httle value in distinguishing 

tumors of the bladder from calculi or cystitis. Evidences of cystitis 

will usually be found in the urine, but this is not invariably the 

case even in the presence of large tumors of long standing. On 

the contrary, the bladder wall may present a normal appearance or 

may be ansemic. The loss of blood may be so great as to produce 

a high degree of anaemia and exhaust the strength of the patient. 

The presence of cyhndrical cells in the urine is regarded by some 

authorities as conclusive evidence of the existence of a papillary 

growth. 

34 



530 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

Palpation reveals the presence of a foreign growth if it is suffi- 
ciently large. It may be possible to detect infiltration by a malig- 
nant growth in the neighboring tissues. Two fingers inserted into 
the vagina and the other hand on the abdomen may engage the 
tumor. A soft, pedunculated growth may elude detection by this 
method. Such soft, pedunculated growths and all small tumors can 
be detected only by a cystoscopic examination. Direct palpation 
of the tumor through the urethra is an obsolete method. 

Direct inspection gives positive evidence of the presence of a 
tumor, of its size, form, color, and location, of the number of growths, 
whether pedunculated or sessile, ulcerated or intact; also, as to 
whether there exists a cystitis and the extent of the inflammatory 
complications. Through the speculum a piece of the growth may 
be removed for microscopic examination. 



CHAPTER XXXV. 

THE DIAGNOSIS OF DISEASES OF THE UEETEKS. 

Anatomy. 

Physiology. 

Methods of Examination. 

Catheterization. , 

Congenital Anomalies. 

Ureteritis. 

Obstruction of the Ureter. 

Ureteral Calculus. 

Stricture. 
Hydroureter. 
Ureteral Fistula. 

ANATOMY AND PHYSIOLOGY OF THE URETERS. 

Anatomy. The ureters lie behind the abdominal and pelvic 
peritoneum and are slightly movable, flattened cords, extending 
from the kidney to the bladder. Under normal conditions they 
run symmetrically in an irregular, curved course on either side. 
The average length is ten to twelve inches, the left being slightly 
longer than the right because of the higher position of the left 
kidney. 

There is no variation in the diameter of the ureter except at 
either end, where it distends above into the funnel-shaped pelvis and 
below into the ureteral prominence. The average diameter is 5 mm. 

The ureters are traced through the pelvis in a sigmoid course. 

They lie close to the posterior lateral wall of the pelvis beneath 

the peritoneum and near the internal iliac artery. From this point 

they turn forward, passing underneath the uterine artery at the 

base of the broad ligament half-way between the cervix and the 

pelvic wall. They then run parallel to the upper anterior vaginal 

wall and enter the bladder at the upper angle of the trigone. 

Through the bladder wall the ureters run obliquely forward and 

inward. 

(531) 



532 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

The course of the abdominal portion of the ureter, including that 
part running from the kidney to the brim of the pelvis, passes 
forward in a curved direction over the psoas muscle to the brim of 
the pelvis. The ovarian veins and artery join the ureter at a mid- 
point in its course through the abdomen. On the left side it lies 
behind the colon above and the sigmoid below; on the right side it 
lies behind the caput coli and the ascending colon. 

Physiology. The ureters are not merely passive in conveying 
the urine from the kidney to the bladder. A peristaltic wave travels 
from above downward two or three times each minute, imparting 
to the ureters a vermicular movement and forcing the urine onward. 

METHODS OF EXAMINATION OF THE URETER. 

Four methods of examining the ureters are in general use — 
palpation, inspection, catheterization, and sounding. 

Palpation. It is possible to palpate the pelvic portion of the 
ureter through the vagina and rectum. The abdominal portion of 
the ureter cannot be palpated without making an incision into the 
abdomen or lumbar region. 

In palpating the pelvic portion of the ureter the bladder and 
rectum must be empty, all clothing constricting the waist must be 
removed, and the patient placed in the lithotomy position. 

The index finger is inserted high in the vaginal fornix near the 
side wall of the pelvis. Stroking the vaginal wall downward and 
backward, the ureter is felt as a slender cord which slips away 
from the finger. That portion leading from the base of the broad 
ligament to the bladder is most easily felt. The size, consistency, 
mobility, and direction of the ureter serve to identify it in a vaginal 
examination. 

The tendinous arch of the levator must not be mistaken for the 
ureter, nor must the obturator vessels and nerve. Only when the 
abdominal walls are extremely thin can the ureter be palpated at 
the pelvic brim about one and one-quarter inches to the right or 
left of the promontory of the sacrum. 

When the ureter is diseased the line of tenderness will serve as a 
guide. 

. Through the empty rectum and preferably under anaesthesia, the 
ureter can be traced through the pelvis, the left being more acces- 



DIAGNOSIS OF DISEASES OF THE URETERS 533 

sible than the right. Guided by the pulsations of the internal iliac 
artery, beginning at the bifurcation of the common iliac and tracing 
downward, the finger detects a flat, yielding cord running downward 
and forward. The larger and more resisting the ureter, the more 
easily is it palpated. 

A catheter or bougie placed within the ureter to serve as a guide 
will facilitate the outlining of the ureter. 

Inspection. No portion of the ureter can be inspected without 
an incision except that portion lying in the bladder wall which is 
recognized through the cystoscope as the ureteral prominence. 
With the abdomen open the lower abdominal portion and the 
upper pelvic portion may be inspected by drawing the sigmoid 
toward the median line. It is possible to lay bare the abdominal 
portion of the ureter by a lateral incision, drawing the ascending or 
descending colon to the median line. In this way the peritoneal 
cavity is not opened. The ureter is found lying upon the psoas 
muscle. 

Catheterization. Both palpation and inspection are of minor 
importance as means of investigating the ureters. Little can be 
positively demonstrated by these methods. By the ureteral catheter 
we may diagnose to a certainty the patency of the ureter, the exist- 
ence of ureteral calculi, foreign growths, strictures, hydroureter, 
pyoureter, and many of the lesions of the kidney to be considered 
later. 

The urine from either kidney is collected without mixing with 
that of the opposite kidney or with the foreign elements in the 
bladder and urethra. 

By the Nitze method the catheter is introduced through the canal 
in the instrument. The usual technique of a cystoscopic examina- 
tion is carried out. 

In the Kelly-Pawlik method and preferably in the elevated 
lithotomy position, as devised by Webster and Pryor, the catheter 
is directed through an endoscope after a thorough inspection of 
the bladder. In this method the instruments employed are a conical 
urethral dilator, obturators, specula ranging in size from 8 to 10, 
head mirror, natural or artificial light, an evacuator, searcher, long, 
curved mouse-toothed forceps, and a flexible ureteral catheter. 
For special purposes there may be added hard-rubber bougies, a 
metal ureteral catheter, and a series of dilating catheters. After 



534 DIAGNOSIS OF niSEASJES OF THE URINARY SYSTEM 

thoroughly inspecting the bladder as advised by Kelly the ureteral 
orifices are located by what is called a searcher. When no diffi- 
culty is experienced in locating the ureteral orifice or prominence 
the searcher may be dispensed with and the catheter at once directed 

Fig. 220 




Simultaneous catheterization of the ureters. The urine may be collected from either 
kidney in separate sterile tubes and for an indefinite period. The above method is suggested 
by Kelly. 



to the ureter. A metallic searcher is made to lightly impinge against 
the mucous membrane in the supposed location of the ureteral 
orifice. No force is to be used for fear of perforating the bladder. 
The searcher separates the lips of the orifice, which now present 
a dark, rounded opening, and is allowed to drop into the ureter 



DIAGNOSIS OF DISEASES OF THE URETERS 535 

by its own weight. It serves as a guide to the catheter, which is 
directed to the ureteral orifice. As the catheter enters the ureter 
the searcher is withdrawn by an assistant. 

A -flexible catheter has many advantages over one made of metal 
or non-flexible rubber. It readily follows the course of the ureter 
to the pelvis of the kidney, and there is little danger of injuring the 
ureter. When it is desired to catheterize the ureter without enter- 
ing the pelvis of the kidney a shorter catheter may be employed, 
one measuring twelve inches, whereas, it would require a catheter 
twenty inches in length to extend to the kidney. It is essential 
that the catheter have a perfectly smooth surface and a blunt, 
rounded end with an oval eye near the tip. A wire stylet is required 
to give stiffness to the catheter as it is forced through the ureter. 

Where the bladder can be inspected without an anaesthetic it is 
usually possible to introduce a catheter without causing great dis- 
comfort. 

It is important to thoroughly sterilize the catheters both before and 
after using. All foreign particles must be removed from the lumen 
of the catheter. This can be done by means of a stylet and by 
forcibly injecting water through the catheter. They should always 
be kept straight, for when allowed to roll up the varnish cracks and 
chips off. When both ureters are to be catheterized the speculum 
is withdrawn and reinserted beside the first catheter. When one 
ureter is catheterized and there is difficulty in passing a catheter 
into the other ureter, a fairly accurate method of separately col- 
lecting the urine is found in completely emptying the bladder, after 
which a large catheter is placed in the urethra. All urine collect- 
ing in the bladder while the ureteral catheter is in place is assumed 
to come from the opposite kidney, and especially is this true when 
the separate collections differ in character. 

When, on account of an infected bladder, it is inadvisable to 
pass a catheter into the uterus, Kelly advises collecting a few 
drops of urine directly from the ureteral openings. This amount 
will serve for a microscopic examination. When the ureter is tor- 
tuous or the calibre is constricted, it may be impossible to introduce 
a flexible catheter. Here a metal catheter will be of service, but 
must be used with caution for fear of injuring the ureter. 

Bougies made of hard rubber, two milhmetres in diameter and 
twenty inches in length, are of service in locating ureteral calculi 



536 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

and in dilating strictures in the pelvic portion of the ureter. It is 
possible to push the bougies into the pelvis of the kidney without 
inflicting injury. A bulbous enlargement is placed about seven 
millimetres back of the point. These bulbs vary in size from a 
little more than the diameter of the instrument to four millimetres. 

Kelly has ingeniously devised a wax tip for the bougies, by which 
he is enabled to locate calculi in the ureter and pelvis of the kidney. 
Longitudinal grooves are made on the sides of the tip for the pur- 
pose of retaining the dental wax. A silk renal catheter tipped with 
wax will serve the purpose equally well. The scratch marks made 
by the calculi are seen under a low magnifying glass. Where the 
a:-rays fail to detect the stone it is often possible to locate it by 
wax-tipped bougies. 

Kelly gives the following summary in a recent article on " Scratch 
Marks on the Wax-tipped Catheter in the Diagnosis of Stone in 
the Kidney or Ureter:" 

(a) The scratch marks afford a valuable confirmation of the find- 
ings of the x-ray plates. 

(6) The wax-tipped catheter serves to distinguish phleboliths 
about the vault of the vagina and in the pelvic veins from ureteral 
calculi. 

(c) In the cases of stout women, where the x-YQ.y findings are 
unsatisfactory and the repeated use of the ir-ray is dangerous. 

{d) In cases of uric acid and uratic calculi, where the a:-ray 
shadow is faint, leaving doubt as to the diagnosis. 

{e) In extemporized, hurried investigations, when the or-ray 
apparatus is not conveniently accessible, and more especially in 
retrograde catheterization from the pelvis of the kidney downward 
in the course of a renal operation, to determine whether there are 
any calculi lodged in the ureter. 

(/) In fibrous or old inflammatory thickenings about the renal 
pelvis, which give a shadow on the photographic plate exactly like 
a stone. 

Examination of the Urine Collected from the Ureters. Fol- 
lowing the suggestions of Kelly five things are inquired into in 
making a thorough examination of the urine collected directly 
from the ureter and kidney. 

1. The amount of fluid escaping at once upon the introduction of 
the catheter. 



DIAGNOSIS OF DISEASES OF THE XJRETEBS 537 

2. The rate of flow during catheterization. 

3. Physical properties, specific gravity. 

4. Chemical properties. 

5. Bacteriological condition. 

The following points are observed in securing separated urines 
(Kelly): 

1. The exact time of introduction of each catheter is noted. 

2. The time of withdrawal is noted and also written on a card, 
giving the exact duration of the flow. 

3. The exact amount of secretion collected in the test tube is 
noted. 

4. It is well to compare the rate of secretion, determined by 
noting the amount of flow in a given unit of time, say from five to 
fifteen minutes or longer, with the entire amount passed in the 
twelve hours during which the examination is made. If the amount 
secured is too small or too large the error may be rectified in this 
way. A nervous patient, for example, will sometimes pass an 
excessive amount through the catheter. 

5. An analysis of each urine is made, investigating its physical, 
chemical, microscopic, and bacteriological characters. Especial 
attention must be paid to the urea as the most important repre- 
sentative of the physiological activity of the kidney. 



DANGERS INVOLVED IN THE CATHETERIZATION OF THE 

URETER. 

1. Direct injury to the mucous membrane of the ureter and 
bladder, thereby creating an atrium for infection. 

2. Ureteral fever not unlike urethral fever caused by the passage 
of the ureteral catheter. 

3. Cicatrization of the ureteral opening into the bladder follow- 
ing upon trauma produced by the catheter. 

4. Breaking off a piece of the catheter in the ureter. 

5. Infection of the ureter and kidneys possibly leading to a fatal 
issue. 

In view of these dangers the indiscriminate use of the ureteral 
catheter is to be deprecated. It should be used only as a last resort 
and with extreme caution. 



538 DIAGNOSIS OF DISEASES OF THE URINABY SYSTEM 

CONGENITAL ANOMALIES IN THE DEVELOPMENT OF THE 

URETERS. 

1. Absence of one or both ureters. 

2. Occlusion of part or all of the lumen, 

3. Double ureter. 

4. Ectopic ureteral orifice. 

5. Dilatation of a partially occluded ureter. 

6. Bending and twisting of the ureter. 

1. Absence of one or both ureters is usually associated with an 
absence of the corresponding kidney. 

2. Occlusion of part or all of the lumen of the ureter is associated 
with atrophy and cystic degeneration of the coi:responding kidney. 

3. A double ureter, while not often found, is the commonest of all 
congenital defects of the ureter. The ureter may be double in any 
portion of its course or may begin in separate and distinct pelves 
of the kidney and open separately into the bladder. 

A double ureter may be unilateral or bilateral. The condition 
has no clinical significance. The clinical diagnosis is inferred by 
the discovery of two separate and distinct ureteral openings into 
the bladder and by the passage of bougies and catheters into each 
of the ureters. 

4. An ectopic ureteral orifice presents at a point outside the bladder. 
Very often this is found in the urethra and vagina. 

Incontinence of urine is the complaint of the patient. The diag- 
nosis is based upon direct inspection first of the vulva, next of the 
vagina through a speculum, of the urethra through a urethroscope, 
and, finally, of the bladder through a cystoscope. 

The opening will be recognized as ureteral by seeing an intermit- 
tent flow of urine pass from it. 

To determine whether there is a second ureteral opening on the 
same side a cystoscopic examination is made. A catheter or bougie 
passed into the opening will be directed to the corresponding kidney. 

5. Dilatation of a partially occluded ureter is a rare finding. The 
corresponding kidney becomes atrophied and cystic unless there is 
an additional outlet to the urine. 

6. Bending and twisting of the ureter is associated with hydro- 
nephrosis, which, in time, may result in complete cystic degenera- 
tion of the kidney. 



DIAGNOSIS OF DISEASES OF THE URETERS 539 

INFLAMMATION OF THE URETER. 

Ureteritis rarely exists apart from a similar involvement of the 
bladder or kidney, and is usually secondary to these lesions. 
The causes of ureteritis are: 

1. Extension downward from the kidney. 

2. Extension upward from the bladder. 

3. Foreign bodies lying within the ureter. 

Tuberculous urethritis is most often primary in the kidney, 
extending downward to the ureter and finally involving the bladder 
and urethra. 

Primary ureteritis is rare and probably only arises as the result 
of injury by a ureteral catheter or stone. Secondary ureteritis 
arises from extension downward from the kidney or upward from 
the bladder. 

Predisposing causes confined to the pelvis are cancer and fibroid 
tumors of the uterus, the pregnant uterus, pelvic inflammatory 
lesions originating in the genito-urinary tract. 

Morris says that pregnancy may be the starting point of uretero- 
pyelitis without the development of cystitis. 

The streptococcus, staphylococcus, and gonococcus infections 
almost invariably begin in the urethra or bladder and extend 
upward to the ureter and kidney. 

It is a matter of common observation that an infection may be 
conveyed from the bladder to the kidney without leaving an evi- 
dent lesion in the ureters, and it is also observed that the secretions 
from the infected kidney may continuously bathe the mucosa of 
the ureters without infecting them, and yet infect the bladder. 

The diagnosis of ureteritis as an independent lesion is seldom 
made; the clinical picture is usually involved in a cystitis or pye- 
lonephritis. The predominant symptoms are usually those of 
pyelitis or cystitis. 

Pain and tenderness along the course of the ureter are the most 
characteristic clinical manifestations of ureteritis. Frequent urina- 
tion with or without pain in the bladder or renal colic is frequently 
the chief symptom. 

It is possible to outline the pelvic portion of the thickened, 
tender ureter by a vaginal examination. The fingers introduced to 
the anterolateral wall of the vagina will follow the cord as it passes 



540 DIAGNOSIS OF DISEASES OF THE XJBINARY SYSTEM 

to the vault of the vagina and on to the side of the cervix. It must 
not be mistaken for a thickened adherent tube or ovary. Through 
the rectum the ureter may be traced to a higher level. 

Tenderness on pressure will serve as a guide to the course of the 
ureter through the abdomen. 

In a cystoscopic examination the ureteral prominence is seen to 
be injected with bloodvessels radiating from the ureteral orifice. 
Cloudy and purulent urine may be seen to drip from the orifice 
into the bladder. 

A ureteral catheter will serve to collect the urine from the affected 
ureter, and this can be compared with the urine from the other 
ureter. 

Tuberculous ureteritis is almost never a primary infection, but is 
usually secondary to tuberculous pyelonephritis. 

We may speak of an ascending tuberculous infection, when the 
ureter is involved secondary to the bladder; of a descending tuber- 
culous infection, when the kidney is primarily infected. The infection 
may descend on one side and subsequently ascend on the other side. 

The walls of the ureter are greatly thickened and the lumen is 
narrowed from thickening and caseous degeneration of the mucosa. 
Healing of ulcerated surfaces may result in a cicatricial contraction 
and obliteration of the lumen; the ureter may be further obstructed 
by a plug of caseous material. This obstruction leads to hydro- 
nephrosis, and, finally, to cystic degeneration of the kidneys. A 
tuberculous pyonephrosis will almost inevitably result from such 
obstruction. 

The symptoms are the same as found in ordinary forms of ureter- 
itis, only they are more pronounced. 

In advanced cases blood is found in the urine. Pus is invariably 
present in the urine, and in it tubercle bacilli are occasionally 
found. A positive clinical diagnosis can only be made by finding 
the tubercle bacillus in the urine catheterized from the ureters. 
When found in the presence of a thickened, tender ureter, the diag- 
nosis of tuberculous urethritis is established. 

The smegma bacillus closely simulates the tubercle bacillus in its 
size, form, and staining qualities. It is found in the secretions of 
the external genitals, and is not to be confounded with the tubercle 
bacillus. In a catheterized specimen no smegma bacilli will be 
found. 



DIAGNOSIS OF DISEASES OF THE URETERS 541 

Inoculation experiments may be carried out on guinea-pigs and 
rabbits, with promising results. Injections with tuberculin as a 
diagnostic measure have been made, with positive results. 

The finding of tuberculosis in the bladder or kidney, associated 
with an irregularly thickened tender cord, should establish the 
diagnosis of the tuberculous ureteritis to a high degree of probability. 

OBSTRUCTION OF THE URETER. 

The ureter is more frequently obstructed in women than in men 
— a fact to be explained by the pressure exerted upon the ureter by 
swellings of the uterus, tubes, and ovaries. 

Causes. The following classification is made by Kelly: 
First, causes acting from without and occluding the ureter by 
pressing upon it, such as: 

1. Ovarian tumors. 

2. Uterine tumors. 

3. Cancerous infiltration of the broad ligaments. 

4. Cancer of the csecum. 

5. Retroperitoneal pelvic sarcoma. 

6. Aneurysm of the iliac artery. 

7. Scar tissue in the broad hgament. 

8. Perineuritis. 

9. An omental adhesion to the pelvic brim. 

10. Thickened bladder walls. 

11. Sarcoma of the bladder. 

12. Pedunculated tumor of the bladder. 
Second, foreign bodies lodged in the ureteral canal: 

1. Calculus. 

2. Blood clot. 

3. Echinococcus cyst. 

Third, affections of the ureteral walls themselves: 

1. Ureteritis bacilli coli communis. 

2. Ureteritis gonorrhoeica. 

3. Ureteritis tuberculosa. 

4. Valve formation in the ureteral wall. 

5. Gumma in the wall. 

6. Cancer of the ureter. 

7. Psorospermial cysts. 



542 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

The point of obstruction is most frequent in the pelvic portion 
of the ureter. Here the ureter is often engaged between the unyield- 
ing bony wall of the pelvis and various tumors and inflammatory 
swellings within the pelvis. One or both ureters may be involved. 

The diagnosis involves not only the fact of obstruction to the 
ureter, but the determination of the cause of the obstruction, its 
location, the rapidity with which it has developed, and the extent 
of the obstruction. 

The clinical manifestations are variable and unreliable. Pain in 
the region of the kidney and ureter is the most constant symptom, 
yet a moderate degree of obstruction may exist without causing 
symptoms. The more rapidly the obstruction develops the greater 
are the clinical disturbances. 

Frequent painful urination suggests an inflammatory obstruction 
or a calculus. Symptoms are particularly unreliable as a guide to 
the diagnosis in a slowly developing obstruction. Where the ureter 
has been suddenly plugged with a calculus or blood clot, the inten- 
sity and location of the pain are so characteristic as to frequently 
serve for a diagnosis. 

In making a diagnosis of obstruction of the ureter all causes 
above enumerated are to be sought for. All swellings of the pelvis 
are to be outlined in a bimanual examination. Where there is 
frequent, painful urination and the cause of the disorder cannot be 
located in the ureter or bladder, it becomes imperative to explore 
the ureters by bougies and catheter. An inflammatory swelling of 
the ureter palpated through the vaginal wall suggests a probable 
cause for the obstruction, but does not eliminate the possible exist- 
ence of other causes. 

The only positive means of locating an obstruction in the ureter 
is by the passage of a bougie or catheter. The instrument will 
meet with an obstruction at a point below the pelvis of the kidney, 
or after passing a given point with some resistance the constricted 
portion grasps the instrument so as to resist its withdrawal. Occa- 
sionally when passing a ureteral catheter no special resistance will 
be noticed until there appears a sudden discharge of an unusual 
amount of fluid which has accumulated behind the obstruction. 

Ureteral Calculus. Calculi may lodge at any point in the course 
of the ureter, but are most often found near the pelvis of the kidney, 
the floor of the pelvis, and the flexure at the pelvic brim. These 



DIAGNOSIS OF DISEASES OF THE UBETEBS 



643 



Fig. 221 



calculi are elongated and cone-sliaped. They are of rare occur- 
rence. 

The diagnosis is based upon the periodic recurrence of a colicky 
pain radiating from the kidney along the course of the ureter. 
Following these attacks of pain there may be a rise of temperature 
and the appearance of blood in the urine. 

The symptoms are the same as those of renal calculi. 

The passage of a calculus along the ureter is suspected when 
pain, tenderness, and hsematuria have persisted for several days 
and the tenderness is found to de- 
scend along the course of the ureter 
from time to time and is finally located 
in the bladder. 

Occasionally the stone will act as 
a ball-valve in plugging the ureteral 
opening of the pelvis of the kidney. 
In such an event there will be a 
temporary hydronephrosis with inter- 
mittent discharge of the contents 
through the ureter. Under favorable 
conditions a stone may be palpated 
through the vaginal wall, rectum, or 
abdominal wall. In rare instances a 
stone has been seen through a cysto- 
scope to project from the ureter into 
the bladder. 

When the stone lies higher up in 
the ureter it is detected with abso- 
lute certainty by passing a catheter 
or sound. The device practised by 
Howard Kelly of tipping the catheter 
or sound w^ith wax is of special ser- 
vice in these cases. 

Stricture of the Ureter. Direct , ^ ^ ^ ^, • 

Hydroureter and hydronephrosis. 
violence is seldom the cause of Stric- The ureter and pelvis of the kidney are 
, n ii j^ 1 £ V J distended with urine. The obstruction 

ture of the ureter because ot its deep- ^^3 due to adhesions in the pelvis. 
seated position. The passage of a 

stone may result in a stricture, as may also long-standing inflamma- 
tory lesions in and about the ureter. A few are of congenital origin. 




644 DIAGNOSIS OF DISEASES OF THE UEINABY SYSTEM 

The urine may be voided frequently and with pain. There are 
no findings in the urine to suggest the diagnosis. Tenderness in 
the flanks is a common complaint. There may also be pain in the 
bladder. When the stricture is within or below the broad liga- 
ment it may sometimes be palpated through the vagina as a firm 
cord. 

Hydroureter and hydronephrosis develop when the passage 
of the urine is obstructed. Pyoureter and pyonephrosis may de- 
velop secondary to an obstruction in the ureter and are dependent 
upon a pyogenic infection. These conditions are diagnosed by the 
passage of a catheter beyond the point of obstruction and the empty- 
ing of the accumulated fluid. Abdominal palpation may detect a 
cystic swelling. Continuous pain or intermittent colic in the region 
of the kidney and ureter are highly suggestive of the condition, 
though no positive diagnosis can be made without an exploratory 
puncture through an incision in the back or catheterization of the 
ureter. 

URETERAL FISTULA. 

A fistulous communication may be established between the ureter 
and the abdominal wall or some part of the genital or alimentary 
tract. Part or all of the urine may be directed into these struc- 
tures. 

The majority of ureteral fistulse are caused by direct injury in 
vaginal and abdominal operations and in labor. Other causes are 
ulcerations following tuberculosis, carcinoma, and foreign bodies 
of the ureter. Rarely are the fistulse congenital. 

The diagnosis does not involve great difficulties. When but a 
single ureter is involved the urine is being constantly lost, while at 
the same time the bladder is filled and emptied at natural intervals. 
Were there present a vesicovaginal or vesicouterine fistula, such an 
event would be impossible. 

A colored sterile fluid (milk, permanganate of potassium) may 
be injected into the bladder, and if the urine continues to return 
clear no vesicovaginal fistula is present; the fistula must neces- 
sarily be ureteral. 

Positive evidence is obtained by exposing the ureteral opening 
by means of a cystoscope and passing a sound or catheter into the 
ureter. 



DIAGNOSIS OF DISEASES OF THE URETERS 545 

INJURIES OF THE URETER. 

The ureter may be cut, torn, ligated, or clamped. In a vaginal 
hysterectomy ligature of the adjacent cellular tissue may so com- 
press the ureter as to cause it to subsequently slough and give rise 
to a ureteral fistula. The pelvic portion of the ureter is far more 
frequently injured than the abdominal portion. 

Diagnosis. The diagnosis may not be made for many days, 
weeks, or months after the injury. This is accounted for by the 
time required for the slough to give way and the urine to escape 
through the vagina. It is possible for ligatures to obstruct the 
urine and lead on to complete atrophy of the kidney without being 
recognized. If the urine escapes into the free peritoneal cavity 
and is septic a septic peritonitis will follow; if not septic no infec- 
tion of the peritoneum will necessarily follow and the urine will 
either collect in the peritoneal cavity or escape from the vaginal 
incision. 



85 



CHAPTER XXXVI. 

THE DIAGNOSIS OF DISEASES OF THE KIDNEY. 

Topography. 

Methods of Exl^mination. 
Movable Kidney. 
Enlargements of the Kidney. 

Hydronephrosis. 

Pyonephrosis. 

Perinephric Abscess. 

New-formations. 
Renal Calculi. 

Topography of the Kidneys. The kidneys are located in the 
lumbar region. They usually extend from the twelfth dorsal to the 
third lumbar vertebra; the left lies at a little higher level than the 
right. 

METHODS OF EXAMINATION OF THE KIDNEY. 

The kidney may be examined by inspection, palpation, and 
percussion, with varying degrees of success. Recourse to catheteri- 
zation of the ureters and exploratory incisions are often necessary, 
but should be reserved as a last resort. Their indiscriminate use 
cannot be too strongly condemned. 

1. Inspection is to be carried out with the patient in a variety 
of positions — i. e,, on her back, abdomen, on either side, when 
sitting and standing. (See Plate LVIII.) 

If the kidney is normal in size and position nothing can be ascer- 
tained by inspection. A floating kidney may bulge upon the ante- 
rior wall of the abdomen with the patient in the erect position or 
leaning forward. It is rare that the lateral abdominal walls are 
expanded by a movable kidney. 

2. Palpation of the normal kidney in its normal position is pos- 
sible under favorable conditions. The most favorable position is 
the recumbent, with the back flat upon a firm table or mattress, 

(546) 



DIAGNOSIS OF DISEASES OF THE KIDNEY 



547 



Fig. 222 



the shoulders shghtly elevated and the knees flexed. The 
fingers of the left hand steadily and firmly press upon the lumbar 
muscles immediately below the costal arch. The fingers of the 
right hand are pressed into the abdominal wall just below the 
costal arch between the anterior axillary and nipple lines. The 
lower third or half of the kidney should be palpated under per- 
fectly normal conditions. If the patient is instructed to take a 
long-drawn sigh the kidney is 
made to descend to the lowest 
possible level and is grasped 
between the two hands as the 
abdominal wall relaxes during ex- 
piration. 

3. Renal ballottement is ehc- 
ited by quickly compressing the 
kidney backward and forward 
against the opposite hand. The 
impact is not always discerned, 
but seldom fails when the kidney 
is large or when movable and the 
abdominal walls thin and relaxed. 

Little or no pain is experienced 
from palpating a normal kidney 
or new-formation of the kidney. 
When a calculus is present or the 
kidney inflamed there is more or 
less tenderness. As with the uterus 
so with the kidney we recognize 
by palpation the position, size, 
mobility, form, and sensitiveness to pressure. We must, therefore, 
regard palpation as a method of the greatest value. 

4. Percussion is of little value in the physical examination of 
the kidney. Unless the kidney is very greatly distended there will 
be a tympanitic note over the kidney anteriorly, which serves to 
distinguish the right kidney from the liver and the left kidney 
from the spleen. Posteriorly percussion is of still less value. Be- 
tween the kidney and the vertebral column there is no area of 
resonance. This, however, is of little value in dealing with en- 
largements of the kidney. 




Vertical section of kidney. (Gray.) 



548 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

5. Catheterization of the ureters is discussed on page 536. 

6. The x-rays were formerly relied upon more than at the present 
time. At times they prove most satisfactory, but in general they 
are unreliable in the diagnosis of renal calculi. Not only does a 
shadow often fail to appear when a stone is present in the kidney, 
but a shadow has been repeatedly found to indicate the presence 
of a stone when an exploratory operation failed to find it. 

7. Exploratory incisions are justifiable as a last resort in all 
enlargements of the kidney and in calculi. The natural range 
of movements varies, but probably does not exceed one and one- 
half inches. 

MOVABLE KIDNEY. 

Under normal conditions the kidney is firmly embedded in fat 
and is supported by the fat, the overlying peritoneum, and the 
renal bloodvessels. (See Plate LIX.) 

A movable kidney may be a congenital lesion, but is almost 
invariably acquired. Kuttner collected 667 cases, of which 584 
were in women and 83 in men. The same author observed the 
right kidney movable in 553 cases, the left in 81, and both in 93. 
According to Edebohls, about 20 per cent, of gynecological cases 
have a movable kidney. Tight lacing and pregnancy account for 
the greater frequency in women. Other exciting causes are heavy 
lifting, absorption of the perirenal fat, and an enlarged liver or 
spleen crowding the kidney out of 'place. The greatest number 
occur in the period of sexual maturity, though the lesion is not 
unknown in infancy and old age. 

The explanation for the occurrence of a movable kidney follow- 
ing upon labor lies in the sudden decrease in the intra-abdominal 
pressure, the great muscular exertion exercised during labor, the 
relaxed abdominal supports after labor, and early rising from 
childbed. 

Movable kidney is especially frequent in women with long 
narrow chests in whom there is not room for the kidney to occupy 
its proper place. In these women there is usually a deficiency in 
perirenal fat. The cause is occasionally found in a blow, kick, 
or crushing injury. 

' Three degrees of mobility are recognized: the palpable kidney, 
when the range of motion is limited, yet the kidney can be pal^ 



PLATE LVIII. 




Situation of the Viscera. 

Outlines of heart and vessels — broad red lines. Margins of lungs and individual 
lobes — dotted green lines. Limits of pleural sacs — solid green lines Liver — red 
shading. Stomach — green shading. (In part after His-Spalteholz and Luschka.) 



PLATE LIX. 




FIG. 1. 




ui 




Movable Kidney. 



..ii 



\: b' 



FIG. 2. 





Sarcoma of the Right Kidney. 



DIAGNOSIS OF DISEASES OF THE KIDNEY 549 

pated; movable kidney, when the range of motion is not below the 
level of the umbilicus and is behind the peritoneum; and -floating 
kidney, when the kidney can be moved beyond the median line of 
the abdomen and below the level of the umbilicus. It is possible 
for the kidney to be at the brim of the pelvis. A palpable kidney 
may be converted into a movable kidney, and this in turn into a 
floating kidney. 

The Diagnosis. The diagnosis is seldom difficult. The kidney is 
usually recognized by its position, size, form, consistency, sensitive- 
ness, and replaceability. No symptoms may be complained of in 
the lesser degrees of mobility. Those commonly complained of are : 

1. Pain, which is often complained of as a dragging, weighty 
sensation in the side and back, as an acute pain between the 
shoulders, and more rarely as distinct paroxysms resembling renal 
colic. The pain is usually relieved by lying down and aggravated 
by standing and walking. During the attacks of renal colic the 
kidney is sometimes felt to be sensitive and distended by the 
obstructed urine. The urine is often scant and may contain albu- 
min, casts, and blood. Shortly after the attack has passed there 
may be polyuria followed by a quick return of the urine to the 
normal amount. In the great majority of cases the urine is 
negative. 

2. Digestive disorders are frequent and important complaints. 
They consist of nausea, vomiting, anorexia, constipation, or con- 
stipation alternating with diarrhoea. 

Dietl's crises are acute attacks of colic associated with nausea 
and vomiting, often with abdominal tenderness and distention. 
These attacks may be followed by collapse and death. The ex- 
planation for the crises lies in the twisting and kinking of the 
pedicle of the kidney. Temporary kinking of the ureter leads to 
hydronephrosis and permanent kinking to atrophy of the kidney. 

3. General nervous disturbances may arise and no doubt are 
aggravated by a movable kidney, but their clinical importance is 
not to be overestimated. 

On physical examination the kidney is recognized by its charac- 
teristic shape, size, outline, sensitiveness to pressure, and, finally, 
by the ability to replace it to the normal location of the kidney. 
The importance of more than one examination where a movable 
kidney is suspected and is not recognized on first examination is 



550 JyiAGNOSiS OF DISEASES OF THE URINARY SYSTEM 

emphasized by the fact that a movable kidney is not at all times 
movable, nor can it at all times be dislodged from its normal loca- 
tion. 

When the kidney is recognized as movable we are not to at once 
conclude that the symptoms complained of are caused by the mov- 
able kidney. A careful consideration of the pelvic and abdominal 
organs and of the general temperament of the patient is absolutely 
essential to a final matured judgment. 

Differential Diagnosis. Enlarged Gall-bladder. This is more 
often mistaken for a floating kidney than any other condition. 
With a distended gall-bladder there is no less mobility than is com- 
mon to a movable kidney. It is impossible to crowd a gall-bladder 
downward. It remains in close proximity to the abdominal walls 
in any position the patient may assume, while a movable kidney 
will shift its position. It may be possible under anaesthesia to pal- 
pate the kidney independently of the gall-bladder. It occasionally 
happens that the two conditions are associated. Both conditions 
are more frequently met with in women than in men, and the right 
kidney is far more often movable than the left. 

In the case of gall-bladder distention there is commonly a his- 
tory of jaundice at some time in the course of the disease. 

Movable Spleen. A movable left kidney may be mistaken for a 
movable spleen. In the absence of a movable right kidney it may 
be assumed, with a fair degree of assurance, that the left kidney 
is not movable. I have never seen the left kidney movable and 
the right kidney fixed in its normal position. A movable spleen 
will be identified apart from the kidney by the absence of splenic 
dulness at the normal situation of the spleen, by the notch in its 
inner border which is in contrast to the rounded depression in the 
kidney, and, lastly, by palpating the kidney independently of the 
spleen. 

Ovarian and uterine tumors, cancer of the pylorus and pancreas, 
pancreatic cysts and a "corset liver," have been mistaken for 
movable kidney. 

ENLARGEMENTS OF THE KIDNEY. 

The lesions tending to enlarge the kidijey are hydronephrosis, 
pyonephrosis, abscess, perinephric abscess, and new-formations. 



DIAGNOSIS OF DISEASES OF THE KIDNEY 55I 

Such enlargements may be detected by palpation and percussion. 
Comparison of the two kidneys will be of value in estimating the 
increase in size. 

Hydronephrosis consists in a distention of the pelvis of the kid- 
ney with urine, and is caused by an obstruction of the ureter (see 
page 541). It is congenital in about one-third of all cases. The 
most frequent causes are renal calculi, pressure from surrounding 
tumors, and kinking of the ureter in a movable kidney. Less com- 
mon causes are urethral stricture, peritonitic bands and adhesions, 
enlarged glands, exostosis and strictures resulting from traumatisms. 
Of all causes of hydronephrosis by far the greatest is malignant 
pelvic lesions. Retroflexion of the uterus with adhesions has been 
known to cause hydronephrosis. One or both kidneys may be 
distended or the distention may be confined to a part of one kidney. 
The distention of but one calyx has given rise to an abdominal 
tumor. Malignant and inflammatory lesions in the bladder may 
obstruct the ureteral opening. The healing of ulcers in the ureter 
and about the ureteral prominence in the bladder is known to 
obliterate the lumen of the ureter. 

Whatever the cause of obstruction to the urine in the ureter, 
there is an accumulation of urine in the pelvis and infundibulum. 
As the tension increases the papillae atrophy, and, finally, the kid- 
ney becomes almost completely atrophied and replaced by cystic 
spaces. 

However great the distention, there is nearly always some renal 
tissue to be found. 

A strange observation is that hydronephrosis is most extreme 
where the obstruction is not complete and where the urine is dis- 
charged intermittently. Where the obstruction is complete the 
kidney usually atrophies, and hydronephrosis may not develop. 
The distention may be enormous, filling the entire abdomen; this 
distention suggests the presence of an ascitic accumulation or an 
ovarian cyst. The proportion of hydronephrosis causing an abdom- 
inal tumor is very small. 

Hydronephrosis has been known to distend the abdomen like a 
large ovarian cyst. 

The Diagnosis. On physical examination a tumor occupies the 
renal region. When in doubt as to the nature of the swelling, it 
should be aspirated. The fluid of hydronephrosis is clear or turbid, 



552 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

and there are present urea, uric acid, and some albumin. In cases 
of long standing the urinary elements may disappear, so that aspira- 
tion can no more than identify the tumor as cystic. Nothing can 
be told of its origin from the aspirated fluid. 

Intermittent hydronephrosis is associated with a movable kid- 
ney in about one-third of all cases of hydronephrosis, and is ex- 
plained in such cases by the occasional kinking of the ureter. The 
pelvis of the kidney distends and discharges at intervals, to again 
refill. It is possible for the fluid to be evacuated and never refill. 
Suppuration may follow, converting a hydronephrosis into a 
pyonephrosis. 

Pyonephrosis (Pyelitis). A purulent secretion collects in the 
pelvis of the kidney. The suppurative process may extend to the 
kidney substance, giving rise to a pyelonephritis. The kidney 
substance atrophies, and little other than the capsule may remain 
to form the abscess sac. The lesion may involve one or both kid- 
neys. Surrounding the kidney is more or less of an inflammatory 
reaction which results either in the formation of fibrolipomatous 
tissue or pus. The fluid contents of the kidney may be pus mixed 
with urine and blood or pus alone. Calculi may be found in the 
pus cavities of the kidney, and are often to be regarded as the cause 
of the pyonephrosis. They may, however, develop secondary to 
the pyonephrosis. The micro-organisms most often found in the 
pus are the colon bacillus, staphylococcus, streptococcus, bacillus 
tuberculosis and proteus 

The causes of pyonephrosis are renal calculi, tuberculosis, acute 
and chronic infectious diseases, decomposed urine in a hydroneph- 
rosis, cystitis from various causes, and, finally, movable kidney. 

Pyogenic organisms are essential to the development of pyo- 
nephrosis. 

The diagnosis is based upon the subjective symptoms of infection, 
upon the local findings in an external examination, catheterization 
of the ureters, and urinalysis. Chills, sweating, and an irregular 
fever may indicate a pus infection. The pain in the renal region 
would suggest the site of the infection, though it must be remem- 
bered that the pain may be late in appearing or wholly wanting. 
The patient becomes anaemic and loses flesh. A tumor mass is 
felt in one or both sides, which is tender to pressure and may assume 
large proportions. 



DIAGNOSIS OF DISEASES OF THE KIDNEY 553 

The size of the tumor varies from time to time, and is in inverse 
proportion to the discharge of pus in the urine. 

The urine always contains pus, usually casts, and sometimes bits 
of renal tissue. The amount of pus in the urine depends upon the 
patency of the ureter on the affected side and the quantity of pus 
produced in the kidney. Hence the quantity of pus in the urine 
may vary from much to nothing. It is acid in reaction unless de- 
composition takes place in the bladder. The quantity is diminished 
unless there is compensation from the other kidney. A positive 
diagnosis is made by an exploratory puncture or incision through 
the back or by a cystoscopic examination and catheterization of the 
ureter and pelvis. It is not only possible to withdraw the pus from 
the pelvis, but permanent cures have been effected by irrigating 
the pelvis of the kidney through a ureteral catheter. 

By catheterizing the ureters it is possible to positively demon- 
strate the involved kidney and to exclude cystitis and ureteritis. 

A bacteriological examination of the pus should be made. The 
presence of tubercle bacilli will identify a tuberculous pyonephrosis. 

Differential Diagnosis. All the lesions which have been enumerated 
in the differential diagnosis of hydronephrosis are to be considered 
here and do not demand repetition. When we have arrived at the 
diagnosis of hydronephrosis or pyonephrosis on the one side as 
opposed to all other conditions we are then to distinguish between 
the two conditions. In doing so we are to remember that febrile 
symptoms speak for pyonephrosis. The presence of pus in the 
urine would be in favor of pyonephrosis, though pus is not invariably 
present, and on the other hand pyuria is known to hydrosalpinx 
— the pus coming from a source below the kidney. The greater 
the tenderness to pressure the more likely is the kidney to contain 
pus. 

Greater difficulty will be experienced in distinguishing pyo- 
nephrosis from a perinephritic abscess. If on repeated examina- 
tions no pus has been detected in the urine, and there have been 
no attacks of renal cohc, the weight of evidence would be in favor 
of a perinephritic abscess as opposed to pyonephrosis. An explor- 
atory incision should be resorted to with little hesitancy inasmuch 
as it would be the proper procedure in either case. 

Is the Lesion Unilateral or Bilateral ? In about half the cases 
both kidneys are involved. Unilateral involvement is more com- 



554 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

mon in the early stage. We assume that one kidney is alone affected 
when the pain, tenderness, and enlargement are confined to one 
kidney, though a positive diagnosis can only be made of a healthy 
kidney on the opposite side by catheterizing the ureter. 

PERINEPHRIC ABSCESS. 

Etiology. Abscesses about the kidney are often observed in 
women. They occur more frequently in adults, but are known in 
infancy and childhood. They may be classed as primary and 
secondary. 

Primary perinephric abscesses are usually traumatic. They 
rarely result from exposure to cold or as a complication of some 
infectious disease. 

Secondary perinephric abscesses constitute the greater number. 
They are the result of infections of the kidney and to a lesser extent 
of renal calculi. Isolated cases occur from extension from sur- 
rounding structures — i. e., appendix, tubo-ovarian abscess, chole- 
cystitis, empyema, abscess of the lung, and perforation of a typhoid 
or tuberculous ulcer of the bowels. 

Diagnosis. The symptoms of a primary affection may disguise 
those referable to perinephritis. As a rule, the symptoms are unmis- 
takable. All the general symptoms of infection are to be expected. 
This includes rise of temperature, chills, sweating, loss of appetite, 
vomiting, and possible delirium. These symptoms will be mani- 
fest in proportion to the acuteness of the infection. The general 
symptoms may approach the typhoid state, and again may suggest 
malaria. The presence of pus may be first indicated by a blood 
examination in the finding of leukocytosis. 

Pain is an early symptom. It is described as deep and aching, and 
sometimes darting pains which are located in the region of the kidney 
and spread in all directions, particularly downward to the thigh, 
hypogastrium, and groin. The pain may cease for some days or 
weeks and again appear. There is a sense of weight and fulness 
in the side. On examination there is a corresponding sense of 
resistance even before the tumor is palpable. Later this resistance 
may give way to fluctuation. The degree of fluctuation is dependent 
upon the amount of pus and the thickness of the abdominal wall. 
The overlying skin may be oedematous or congested. 



DIAGNOSIS OF BISJEASJES OF THE KIDNEY 555 

A peculiar lameness is often an early sign. The patient walks 
with the corresponding leg flexed, the body stooped and leaning to 
the affected side with the hand resting upon the thigh. There is 
an inability to extend the thigh on the affected side. This attitude 
relaxes the psoas muscle and thereby relieves pain. There is noth- 
ing characteristic of the lesion in the urine. 

Differential Diagnosis. 1. Affections of the kidney are often 
associated with perinephritic abscess, and are usually the primary 
lesion. In general it may be said that kidney lesions as compared 
with perinephritis are deeper seated, more circumscribed in their 
outline, the urine usually contains pus and possibly blood casts 
and albumin, and there is no superficial oedema. 

2. Lumbago is accompanied by many symptoms which suggest 
a perinephric abscess. The pain and tenderness are confined to 
the lumbar region and do not involve the front of the renal region. 
There is no sense of resistance or fluctuation to be elicited on pal- 
pating the kidney. 

3. Morbus Coxae. The characteristic attitude of perinephritis 
above referred to, together with pain referred to the hip- and knee- 
joints, suggests tuberculosis of the hip-joint. It will be observed 
in perinephritis that the hip- joint permits of perfect freedom in 
flexing the thigh upon the abdomen and in external rotation, in 
fact the pain is lessened by so doing. There is an absence of pain 
and fulness over the hip-joint, both being elicited at a higher 
level. 

4. Psoas abscess and perinephric abscess are frequently con- 
fused. The pain complained of may be of the same character 
and its location practically the same. Furthermore, the attitude 
of the patient in the two conditions is very similar. There is the 
lateral inchnation of the trunk and the inability to extend the leg 
on the corresponding side. A perinephric abscess has been known 
to rupture into the sheath of the psoas muscle. In such an event 
the diagnosis would be impossible short of an exploratory incision. 
It would then be a psoas abscess formed from a perinephritic 
abscess. The reverse is possible, that is, a psoas abscess may be 
extended into a perinephritic abscess. Evidence of spinal caries 
will aid in establishing the diagnosis. The tendency for psoas 
abscess to point below Poupart's ligament is unusual for a peri- 
nephric abscess. 



556 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

5. Appendicitis. When the lesion is confined to the left side 
there can be no question of appendicitis. When, however, the 
right side is affected perinephritis and appendicitis may show 
identical signs and symptoms. The location and character of the 
pain may be the same in the two lesions; more than this, the attitude 
of the trunk and corresponding leg may be the same, the abscess 
may occupy similar locations, and the area of tenderness may be 
the same. Constipation may be equally stubborn in the two con- 
ditions. We find perinephric abscesses tending to gravitate into 
the appendical region and an appendical abscess finding its way 
to the renal region. It may be said, therefore, that it is not always 
possible to distinguish between the two conditions. That which 
can be most depended upon in the differential diagnosis is the loca- 
tion of the pain. In perinephritis the pain is usually greatest in 
the iliocostal space, whereas in appendicitis the pain is more often 
located in the iliac fossa. 

Is the Perinephric Abscess Primary or Secondary? This 
question naturally follows upon the recognition of the abscess and 
demands solution. Since a large percentage of these cases arises 
from calculi and pyonephrosis we are first to look for evidence 
of renal disease in the history of renal colic and in the finding of 
pus, blood, and casts in the urine. Excluding a renal affection we 
proceed to consider all of the various causes enumerated under 
etiology of perinephric abscess. Finding no cause for the lesion 
it must be regarded as primary. A fistulous communication 
between the abscess and bowel or between the abscess and kidney 
does not in itself indicate that the perinephric abscess is secondary. 

TUBERCULOSIS OF THE KIDNEY. 

Etiology. The essential cause of tuberculosis of the kidney is 
the tubercle bacillus. Tubercle bacilli are conveyed to the kidney: 

1. By way of the lymphatics. 

2. By way of the bloodvessels both in intrauterine and extra- 
uterine life. 

3. By extension from the bladder and ureter. 

4. By extension from surrounding structures. 

The presence of tubercle bacilli in the urine does not necessarily 
imply tuberculosis of the kidney, for it is well known that the organ- 



DIAGNOSIS OF DISEASES OF THE KIDNEY 557 

ism in the blood may be secreteJ by the kidney without infecting the 
kidney. It requires other foreign elements to establish the diagnosis. 
Of the predisposing causes we have: 

1. Age. The period of greatest frequency is childhood and early 
adult life, though no age is exempt from the intrauterine period 
to extreme old age. 

2. Trauma is undoubtedly an etiological factor. A direct blow 
to the loins has been known to be followed by tuberculous infection. 

3. Retention of urine from whatever cause is a predisposing factor. 
Diagnosis. Tuberculosis of the kidney is frequently overlooked 

when comphcating other forms of the disease because of the frequent 
absence of any definite symptoms which would direct attention to 
the kidney. The urine may be perfectly normal with the exception of 
bacilli, which are often overlooked. On the other hand, the symp- 
toms may point unmistakably to tuberculous infection of the kidney. 

1. General Symptoms. The hectic temperature reaching 104° 
in the evening and associated with night-sweats, progressive anaemia, 
emaciation, general weakness, anorexia, oedema of the legs and 
feet, frequent and painful urination, are general symptoms which 
must be regarded as highly suggestive of renal tuberculosis. 

2. Pain in the renal region is an almost constant symptom and 
is often the first evidence of the disease. However, the entire 
course of the disease may be run with no pain. The pain is usually 
associated with tenderness in the loins. Sometimes the pain is 
that of renal colic, which may be explained by the plugging of the 
ureter with caseous masses. 

3. Enlargement of the kidney is to be expected in tuberculous 
nephritis. This is almost invariably the case in the advanced 
stages. Indeed, the enlarged kidney may be the only evidence of 
the lesion. The enlarged kidney may retain its characteristic 
shape or may be irregular in its outline from protruding caseous 
areas, abscesses, or distended pelvis. 

The urine will show some abnormalities in the course of the 
disease. Frequent and painful urination marks a late development 
of the lesion. In the early stages the urine may contain no foreign 
substances, but sooner or later there are added to the urine blood, 
pus, casts, caseous debris, and tubercle baciUi. Haematuria may 
be the first evidence of the disease. In examining the urine for 
the presence of tubercle bacilli repeated examinations of centri- 



558 DIAGNOSIS OF DISEASES OF THE UBINABY SYSTEM 

fuged specimens may be required. It may be necessary to make 
inoculation experiments where cover-slip preparations fail. 

Differential Diagnosis. Renal calculus may present a clinical 
picture of renal tuberculosis in the early stage. Renal colic from 
either cause produces the usual train of symptoms. Following 
the attack of colic it may be possible to find a renal stone or a 
caseous particle in the urine. In all doubtful cases the urine must 
be carefully searched for tubercle bacilli. The a;-ray will be of 
occasional value in diagnosis. The constitutional signs of tuber- 
culosis are to be seriously considered in determining the diagnosis. 
The two lesions may co-exist. 

Suppurative pyelonephritis cannot be distinguished from tuber- 
culous nephritis with certainty without the finding of the tubercle 
bacillus in the urine. It is important to consider the family history, 
to look for tuberculosis elsewhere in the body, and to inquire into 
the development of the disease. 

Tumors of the kidney can usually be distinguished from tuber- 
culous nephritis by the pronounced swelling and the absence of 
pus and tubercle bacilli in the urine; also by the absence of a family 
history and constitutional symptoms of tuberculosis. 

NEW-FORMATIONS OF THE KIDNEY. 

I. Benign. 

1. Fibroma. 

2. Adenoma. 

3. Osteoma. 

4. Angioma cavernosum. 

5. Leuksemic tumors. 

6. Lipoma. 

7. Cysts. 

a. Serous. 

b. Polycystic. 

c. Dermoid. 

d. Hydatid 
II. Malignant. 

1. Carcinoma. 

2. Sarcoma. 

3. Hypernephroma. 



DIAGNOSIS OF DISEASES OF THE KIDNEY 559 

Few of the benign tumors ever attain to a large size. As a rule, 
they are not to be distinguished clinically. 

Frequency of Renal Tumors. While new-formations of the 
kidney are not common they are of sufficient clinical importance 
to demand careful consideration. About 40 per cent, of renal 
tumors are sarcomata, 25 per cent, carcinomata, 12 per cent, cysts, 
11 per cent, adenomata, while other forms are of extreme rarity. 

Age. No age is exempt. These tumors, and especially sarcoma 
and carcinoma, are vastly more frequent in infancy and early 
childhood, though they have been known in the eightieth year. 

Characteristic Features of Renal Tumors. 1. The colon lies 
in front of the tumor unless the growth is extremely large, when 
the kidney may bulge the anterior abdominal wall. In exceptional 
cases the empty colon can be felt in front of the kidney. In tumors 
and other enlargements of the liver the bowel may very rarely 
lie in front of the liver. In splenic tumors the bowel never lies in 
front of the spleen. The position of the bowel is recognized by 
the tympanitic note. Inflation of the colon will assist greatly. 

2. A renal tumor when large may be seen to bulge upon the 
anterior abdominal wall, but it never protrudes backward into 
the loins. Splenic tumors may be seen to bulge both forward and 
backward. 

3. Between the spinal groove and the kidney there is no space 
demonstrated by a tympanitic note, as is the case with the spleen. 

4. Renal tumors may descend on deep inspiration, but not to 
the degree observed in splenic and hepatic tumors. 

5. All surfaces and margins of the kidney are rounded, which 
is in marked contrast to the angular margins of both spleen and 
liver. This does not apply to large tumors occupying a portion of 
the kidney. 

6. The character of the urine is usually highly suggestive. Hsema- 
turia is an all but constant symptom, though the urine may be nor- 
mal where the tumors do not involve the parenchyma, or where 
the ureters are kinked or plugged. 

Differential Diagnosis. 1. Splenic Tumor. On palpation the 
margins of an enlarged spleen are most often sharp and angular, 
and the inner surface presents the double notch. This is in con- 
trast to the well-rounded margins of the kidney. In front of the 
spleen there is dulness on percussion as opposed to the tympanitic 



560 JDIA GNOSIS OF DISEASES OF THE URINARY SYSTEM 

note m renal enlargement where the bowel lies in front of the kidney. 
In the lumbar region there is an area of tympany between the 
spleen and the spine which is not found in renal tumors. The 
author recalls a greatly enlarged and movable spleen in a case of 
splenic anaemia which had been diagnosed as a floating kidney. 
In this case there was an absence of splenic dulness in the normal 
location of the spleen, and the kidney could be palpated quite 
apart from the spleen. 

2. Enlargements of the Liver. The upper border of the kidney 
may occasionally be palpated at its upper margin and found to be 
distinctly separated from the liver. Tumors of the liver rarely 
produce an area of dulness in the loins, as is the rule with renal 
enlargements. There is rarely a tympanitic area over the anterior 
surface of the liver in contrast to findings in renal tumors unless 
they are very large. A corset liver with a projecting tongue-shaped 
lobule may very easily be mistaken for a kidney. Symptoms such 
as jaundice that are referable to a disordered liver will aid in the 
diagnosis. 

3. Ovarian Tumors. The growth of tumors of the ovary is from 
below upward while tumors of the kidney grow from above down- 
ward. There is a dull percussion note over the anterior surface 
and a tympanitic note in the loin; the reverse is the rule with renal 
tumors. The attachment of a cystic tumor to the horn of the uterus 
by a pedicle is characteristic of ovarian cysts. No abnormal con- 
stituents are found in the urine. This may be true in tumors of the 
kidney, but it is the exception when blood and possibly pus and 
epithelium are absent in the urine when a tumor exists in the kidney. 
The absence of foreign elements in the urine may be accounted for 
by the total failure of the kidney to secrete or by plugging of the 
ureter. 

4. Appendical Abscess. It is scarcely likely that an abscess 
about the appendix can be mistaken for a renal tumor if due atten- 
tion is paid to the local and general signs of infection and the dis- 
turbances of the bowel. 

5. Cancer of the Colon. The tumor may occupy the renal region 
and in every way resemble a malignant growth of the kidney. 
There may be tympany in front and dulness in the loin. Further- 
more, there may be such a degree of mobility as to suggest the 
presence of a floating kidney. Hsematuria and albuminuria may 



DIAGNOSIS OF DISEASES OF THE KIDNEY 561 

accompany the growth and make the diagnosis the more obscure. 
Intestinal .symptoms, especially diarrhoea and bloody stools, are 
highly suggestive. Not infrequently the diagnosis must be deferred 
for an exploratory incision. 

6. Tumors of the pancreas are occasionally confused with tumors 
of the left kidney. Pancreatic tumors are located more nearly in 
the median line. The loin is not filled out, nor is it dull on per- 
cussion. 

Diagnosis of the Variety of Tumor Formation. There is no 
way of making a positive diagnosis of the variety of tumor of the 
kidney short of a microscopic examination of an excised piece. 
Early in life the probabilities are in favor of sarcoma. It must be 
confessed that even a microscopic examination does not always 
definitely determine the question of malignancy or benignancy. 

Of the benign tumors of the ovary probably the most frequently 
met with is fibroma. 

Fibromata rarely assume proportions that will permit of a clinical 
diagnosis. They are usually small fibrous bodies located in the 
pyramids of the kidney* Billroth removed a fibromyomatous 
tumor of the kidney which weighed nearly forty pounds, and 
Bruntzel removed one composed of fibrous tissue that weighed 
thirty-seven pounds. 

Adenomata of a benign character frequently appear to the naked 
eye as small yellow bodies distributed throughout the substance 
of the kidney. Doubtless they are often of adrenal origin. They 
have a decided tendency toward malignant degeneration. 

They form a solid or cystic tumor, and are further classified as 
papillary or alveolar. They vary in size from a pea to a large 
orange. 

Osteoma is an exceedingly rare tumor of the kidney. Doubtless 
these growths are more often calcified inflammatory products. 

Angiomata cavernosa are new-formations of reticulated cavernous 
tissue. They are small and are rarely seen. 

Leuksemic tumors are made up of lymphoid cells which form 
isolated white patches upon the capsule. They are sometimes 
malignant. 

Lipomata are rare in the kidney. They cannot be distinguished 
from adenomata when small without the aid of the microscope. 
They seldom grow larger than a hazelnut. 

36 



562 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

. Cysts of the kidney are by no means rare. 

a. Simple cysts are rather common in the senile kidney. They 
are rarely large enough and sufficiently tense to be palpated through 
the abdominal wall. These cysts, which lie superficially, are some- 
times larger than the kidney. They arise in the cortex and project 
upon the surface of the kidney. The contents of the cyst is gen- 
erally serous fluid. They can only give rise to pressure symptoms, 
and in the majority of cases even these symptoms are absent. 

h. Polycystic kidney is a cystic degeneration. The entire kidney 
is transformed into a group of cysts varying in size and number. 
This may increase the size and weight of the kidney many fold. 
The contents of the cyst is clear, serous, and occasionally bloody. 
There are albumin, urea, triple phosphates, cholesterin, uric acid, 
and blood cells in the fluid. The renal substance is atrophied or 
may wholly disappear. The lesion is commonly bilateral. The 
origin of these cysts is not understood. Not a few are congenital, 
but no age is exempt. Obstruction to the outflow of urine is the 
usual explanation. (See causes of hydronephrosis, page 551.) 

A clinical diagnosis is seldom made with certainty. The clinical 
picture is that of hydronephrosis. Morris says that a renal tumor 
on each side, together with symptoms of chronic nephritis, may be 
looked upon as fairly pathognomonic of polycystic kidney. In 
half the cases no tumor is observed and in not more than 10 per 
cent, of the cases both tumors are palpated. Failure to palpate 
these growths is largely due to their thin wall and lack of tense- 
ness. Such a cyst could scarcely be palpated through a thick 
abdominal wall. 

Hydatid cyst of the kidney sometimes forms large tumors. About 
1 per cent, of all hydatid cysts occurs in the kidney. In order to 
reach the kidney, the eggs of the taenia which are taken into the 
stomach pass through the portal circulation or through the lymph- 
atics of the mesentery. 

The diagnosis is made with certainty when a renal tumor is 
discovered together with the presence of the products of a hydatid 
cyst in the urine when examined by the microscope. These particles 
may cause renal colic. Where the cyst does not discharge its con- 
tents into the pelvis of the kidney the true character of the cyst 
can only be demonstrated by an exploratory incision or puncture. 
Hydatid fremitus is rarely demonstrated. 



DIAGNOSIS OF DISEASES OF THE KIDNEY 5^3 

Carcinoma of the kidney is found with the greatest frequency 
between the ages of forty and fifty years. Circumscribed or diffuse 
tumors may occupy the substance of the kidney. The tumor rarely 
grows so large as a sarcoma of the kidney. 

Sarcoma of the kidney is peculiar in that it is frequent in early 
childhood, and grows to an enormous size. In early adult life 
these tumors are relatively rare and appear with increasing fre- 
quency as age advances. 

Diagnosis of Malignant Tumors of the Kidney. The recogni- 
tion of a tumor of the kidney is the first step in the diagnosis. (See 
page 558.) Having established this fact it 'is then possible in 
many cases to establish the malignant character of the tumor. A 
carcinoma or sarcoma of the kidney may exist without giving rise 
to a recognizable tumor. The cardinal symptoms of malignant 
tumors of the kidney are pain, tumor, and hsematuria. It must 
be remembered that other affections of the kidney give rise to the 
same conditions and that one or all of these signs may be absent 
in malignant growths of the kidney. In the early stages the diag- 
nosis is quite impossible. 

HYPERNEPHROMA. 

Hypernephroma has been imperfectly understood until recently. 
Formerly it was confounded with carcinoma, sarcoma, endothe- 
lioma, adenoma, lipoma, and angioma. Grawitz, in 1883, asserted 
that these rare tumors originate from adrenal tissue misplaced in 
the kidney substance during the process of development. 

The growth is very soft, rarely invading the kidney, and is 
enveloped in a capsule. Hemorrhagic areas and cystic spaces are 
common. Metastases to the lungs, liver, and bones are occasionally 
observed. Their growth is very rapid, and they are known to 
attain a large size. They are rarely seen in early life; the time of 
election is between forty and fifty years of age. A beautiful illustra- 
tion of a hypernephroma is seen in an article by C. P. Noble and 
W. W. Babcock in the July, 1902, number of American Gynecology. 

The diagnosis of malignant tumors of the kidney is based upon 
the appearance of blood in the urine, renal colic, general evidence 
of malignancy, and the local signs of a rapidly growing tumor of 
the kidney. 



564 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

HcBmaturia may be the first indication. The blood in the urine 
may be fluid, but sometimes appears as casts of the ureter and 
pelvis of the kidney. Osier says he has never seen these casts in 
the urine except in cancer of the kidney. There is usually no blood 
in the urine in hypernephroma, because the tumor rarely invades 
the kidney substance. 

Pain is not always present even in large tumors. It is located 
in the lumbar region and radiates down to the thigh and urethra. 
Colicky pain may be caused by clogging of the ureter with blood clots. 

The general evidences of malignancy are emaciation and cachexia. 
The symptoms usually develop rapidly, though at times are very 
late in making their appearance. 

A large abdominal tumor in an infant is either a sarcoma of the 
kidney or a retroperitoneal sarcoma of the lymph glands. The 
tumor is small or nodular, and is usually firmly fixed. The descend- 
ing or ascending colon lies in front of the growth unless its enormous 
size crowds the colon to one side. The soft, elastic character of 
the tumor may be mistaken for fluctuation. The percussion note 
is dull except in front, where the tumor is covered with the inflated 
colon. 

The movable renal tumor may be confounded with a tumor of 
the ovary or a pedunculated fibroid of the uterus. A pelvic exam- 
ination will demonstrate the connection of pelvic tumors with the 
uterus. 

Enlargements of the liver and spleen are recognized by their out- 
line, their immediate contact with the abdominal wall, the colon 
lying behind the swelling, and the absence of blood in the urine. 

RENAL CALCULI. 

Kidney stones are formed by the deposition and agglutination of 
the normal and abnormal salts found in the urine. 

Etiology. Renal calculi occur at all ages, from late intrauterine 
life to old age. The period of greatest frequency is from twenty 
to thirty. Males are more frequently affected than females. 

Heredity must be considered. This hereditary tendency is espe- 
cially marked in uric acid calculi. 

The diet has much to do with their development. A highly 
nitrogenous diet or one with abundance of salt especially predis- 



DIAGNOSIS OF DISEASES OF THE KIDNEY 565 

poses to the formation of calculi. Alcohol, and especially beer, 
leads to stone formation. 

Uric Acid Diathesis. Uric acid is precipitated in all urine 
after standing many hours, but where it precipitates in an hour 
or two there is liability to stone formation in the kidney and 
bladder. 

The conditions predisposing to precipitation of the urine and the 
formation of stone are decomposition of the urine, supersaturation 
of the urine with salts, and the presence of abnormal constituents 
in the urine. It has been repeatedly emphasized that renal calculi 
very frequently form about a nucleus of desquamated epithelium, 
micro-organisms, and blood coagulum. Harris has recently demon- 
strated the important role of micro-organisms in the formation of 
renal calculi. He substantiates his statement by the following 
facts: "Precipitation alone does not cause stone. Foreign bodies, 
such as exfoliated epithelial cells, blood clots, or those introduced 
experimentally from without, do not cause stone so long as they 
remain free from microbes. The kidneys frequently eliminate 
microbes with the urine without themselves becoming the seat of 
microbic invasion. These microbes may develop in the urine in 
the pelvis and cause the precipitation of certain salts. The char- 
acter of the precipitate depends not entirely upon the composition 
of the urine, but also upon the kind of microbe present. The 
microbes in developing form zoogloea masses, in and about which 
the precipitate takes place. The agglutination of the particles by 
the zoogloea mass forms the nucleus or starting point of the stone. 
Such zoogloea masses have been formed clinically in the urine. 
The microbe found most frequently in the urine is the colon bacillus. 
It grows in acid urine and under proper conditions causes precipita- 
tion of uric acid and acid urates. Microbes have been found in the 
centre of so-called primary stones. From the clinical side we find 
stones frequently preceded by a history of acute or chronic intes- 
tinal disorders; of suppurative lesions of the skin; of acute infec- 
tious diseases, as influenza, pneumonia, typhoid fever. Women 
very commonly date the beginning of their trouble from a confine- 
ment or imperfect puerperium. These conditions are all such as 
readily account for the presence of microbes in the urine." From 
these facts Harris is led to believe that almost all renal stones are 
of microbic origin. 



k 



566 DIAGNOSIS OF DISEASES OF THE UBINABY SYSTEM 

Certain chemical forms of calculi are recognized. These are: 

1. Uric acid calculi, which is the most common form, ranging 
in size from sand-like particles to stones the size of a man's fist. 
Roberts estimates that they constitute five-sixths of all renal cal- 
culi. They are hard, smooth, and red or fawn color. 

2. Oxalate of lime calculi, which take the form of a mulberry 
and rarely attain large proportions. These are second in point 
of frequency. They are grayish-brown or almost black in 
color. 

3. Phosphaiic calculi, composed of the triple phosphates. They 
are not common as compared with stones of similar composition in 
the bladder. They resemble chalk or mortar. 

4. Cystine, xanthine, indigo, and carbonate of lime very rarely 
form renal calculi. 

Diagnosis. Renal calculi may be passed with little or no dis- 
comfort, and may remain in the kidney without the knowledge 
of the patient. The passage of a single stone may end the difficulty 
or repeated attacks of colic may be followed by the passage of a 
great number of stones. So long as the stone remains buried in 
the kidney substance there will be no renal colic; but when it engages 
in the ureter and will not readily pass, a cramping, lancinating 
pain radiates downward from the kidney. Nausea and vomiting 
may accompany these attacks of renal colic, a chill may precede 
the outbreak, and the temperature often rises to 103°. An initial, 
chill may precede the attack. The following quotation is from 
Montaigne, who suffered for years from stone in the kidney: "Thou 
art seen to sweat with pain, to look pale and red, to tremble, to 
vomit, wellnigh to blood, to suffer strange contortions and convul- 
sions, by starts to let tears drop from thine eyes, to urine thick, 
black, and frightful water, or to have it suppressed by some sharp 
and craggy stone that cruelly pricks and tears thee." 

The pain may be referred to the opposite kidney. The blood in 
the urine is seldom excessive, and may appear only after exertion. 
As a rule, it no more than makes the urine smoky. Pyelitis may 
develop. This is ushered in by a chill and rise of temperature; 
pain and tenderness will be more or less constant in the region of 
the kidney, and pus will appear in the urine. 

From the above clinical manifestations a diagnosis may often be 
established to a high degree of certainty. A positive diagnosis is 



DIAGNOSIS OF DISEASES OF THE KIDNEY 567 

occasionally made by sounding the pelvis of the kidney with a 
wax-tipped ureteral bougie or catheter. 

The a;-ray as a means of recognizing renal calculi has been dis- 
appointing and must be considered of little value. Shadows have 
been obtained where no stone exists, and no shadow has been 
obtained where large calculi were found. 

Differential Diagnosis. 1. Nephralgia due to malaria or hysteria, 
also pain referred to the region of the kidney in abdominal aneurysm, 
certain heart lesions, duodenal ulcer, and pleuropneumonia. In the 
above conditions the pain may be very similar to the renal coHc due 
to the passage of a stone. Nothing abnormal is found in the urine. 

2. Vesical Calculus. There may be the typical symptoms of 
renal calculi, including colic and hsematuria, but the diagnosis can 
be readily cleared up by palpating the stone in the bladder, by the 
use of the sound, and, lastly, by direct inspection through the cysto- 
scope. We are not to overlook the fact that stone may exist in the 
kidney and bladder simultaneously. 

3. Renal tuberculosis in the early stage is difficult to diagnose 
from renal calculi. In their clinical manifestations they are very 
similar. Renal colic and hsematuria may exist in a woman of good 
general health. Such a case may prove to be tuberculous nephritis 
rather than renal calculus. Where doubt exists the urine should 
be carefully searched for tubercle bacilli and guinea-pigs should 
be inoculated with the urine. In renal tuberculosis the pain is 
seldom colicky, and when so the pains are followed by the discharge 
of clots of mucus, blood, or mucopus rather than of calculi. Cal- 
culi are known to exist in tuberculous kidneys. 

4. Ureteritis may very closely simulate renal calculi. Tender- 
ness along the course of the ureter, together with an absence of all 
physical evidences of a kidney lesion, will suggest the location of 
the disease. 

5. Movable kidney may suggest renal calculus by the attacks of 
renal colic. The urine, however, does not contain blood, and in a 
certain percentage of cases a renal tumor is palpated. The occa- 
sional disappearance of the tumor followed by polyuria will sug- 
gest the true nature of the lesion. A movable kidney associated 
with hydronephrosis may also contain a calculus. 

6. Renal tumors may be indistinguishable from renal calculi 
without resorting to an exploratory incision. Renal colic may 



568 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

occur from the passage of blood clots. There is this to distinguish 
the two conditions: the hemorrhage is spontaneous, more profuse, 
and continuous in renal tumors, and it is not controlled by rest or 
excited by exertion. 

7. Lumbago, Intercostal Neuralgia. In these affections the pain 
is not of a colicky nature and is relieved by rest. There is nothing 
in the urine to suggest a renal disorder. 

Diagnosis as to the Kidney Affected. First of all we must 
remember that both kidneys may contain stones. Where pain is 
located in one kidney there is little question as to which kidney 
contains the stone, but when there is no pain or tenderness in either 
kidney the diagnosis becomes difficult and at times impossible 
without an exploratory incision. Unfortunately the ir-rays can- 
not be relied upon. Rigidity of the muscles over the affected kidney 
may be the only local evidence of the affection. Stone confined 
to a single kidney may give rise to pain in both kidneys and be 
very misleading. 



CHAPTER XXXVII. 

THE DIAGNOSIS OF THE CAUSES OF TOO FEEQUENT AND 

PAINFUL MICTURITION. 

Almost all conditions which cause pain in urinating also cause 
frequent urination. The two disorders are therefore best con- 
sidered together. A distinction is clearly made between too fre- 
quent urination and incontinence of urine. The former implies 
an ability to retain the urine for a limited time, while in the latter 
condition the urine is voided as fast as it enters the bladder. 

Either of these disorders may be congenital or acquired. They 
may be continuous or interrupted by intervals of complete relief. 

Causes. 1. Pregnancy. During the first trimester and in the 
last month of pregnancy the patient urinates more frequently, 
though seldom with pain. The explanation lies in the position of 
the enlarged uterus. 

2. Nervous diseases, both functional and organic. Pain is rarely 
present. A hypersesthetic condition of the bladder is the explana- 
tion. 

3. Nocturnal enuresis is a functional disorder attributable to an 
irritable spinal centre. The urinary organs are in a normal state. 
The condition rarely lasts after puberty. 

4. Hypersecretion of urine, as in diabetes and hysteria, will demand 
frequent evacuation of the bladder. 

5. Overdistention of the bladder from an atonic condition of the 
bladder wall or obstruction to the outflow of urine, as from stricture, 
may cause a frequent desire to urinate and the voiding of but a 
small quantity of urine. That which is voided is merely the over- 
flow. Following upon an overdistention of the bladder there may 
be a frequent desire to urinate due to the irritation of the bladder 
and sphincter urethrse. In young women who through false 
modesty urinate at long intervals, the inabihty to long retain the 
urine is frequently acquired. Such a condition may be incurable. 
The author recalls a case of a young woman who habitually retained 

(569) 



570 DIAGNOSIS OF DISEASES OF THE URINABY SYSTEM 

her urine for twenty-four hours, and gave as her reason that she 
did not Hke to go to stool. Such practices cannot fail to result 
disastrously. 

6. Displacements of the uterus and the encroachment of pelvic 
tumors and exudates not seldom cause a frequent desire to urin- 
ate, and if these encroaching structures are tender to pressure 
urination will be painful. In forward displacements of the uterus 
the fundus presses upon the bladder and lessens its capacity. In 
retroversion of the uterus the cervix may cause frequent urination 
by impinging against the urethra and base of the bladder. One of 
the earliest evidences of cancerous invasion of the bladder from the 
cervix is frequent, painful urination, together with the appearance 
of blood in the urine. 

7. Dislocation and diseases of the urethra tend to cause frequent 
and, many of them, painful urination. The reader is referred to the 
discussion of these subjects. 

8. All inflammatory diseases and new-formations of the bladder, 
ureters, and kidneys cause frequent and often painful urination. 
The new-growth which causes most intense pain in urinating and 
is the most frequent cause of painful urination is caruncle. The 
pain thus caused is described as ''shooting," "cutting," and 
"scalding." 

9. Foreign bodies, notably stone, in any portion of the urinary 
tract cause frequent painful urination. 

10. Highly concentrated urine may cause frequent and slightly 
painful urination; these symptoms disappear upon drinking large 
quantities of water. 



GHAPTEE XXXVIII. 

THE DIAGNOSIS OF THE CAUSES OF INCONTINENCE AND 

RETENTION OF URINE. 

1. Incontinence of Urine. No urine is retained in the bladder, 
but escapes as fast as it is conveyed through the ureters. This dis- 
order may be congenital or acquired. As a congenital lesion we 
find defect in the development of the urethra and bladder. The 
bladder may be congenitally small, or there may be a lack of devel- 
opment in the sphincter urethrse. 

Acquired incontinence is most often due to fistulse leading from 
some portion of the urinary tract to the exterior by way of the 
vagina, cervix, uterine body, bowel, or abdominal wall. 

Overstretching of the urethra in the passage of instruments and 
the finger into the bladder may result in temporary and sometimes 
permanent incontinence of urine. 

As a complication of many of the nervous disorders incontinence 
of the urine is frequently observed. 

II. Retention of Urine. 1. Hysteria as a cause of retention of 
urine is little recognized. Too often the catheter is inserted with- 
out recognizing the hysterical element in the case. Tabes dorsalis 
is often associated with retention of the urine. 

2. Pressure upon the urethra, bladder, and ureters by a displaced 
uterus and by new-formations and inflammatory exudates in the 
pelvis and abdomen. 

The cervix in a retroversion, and especially when the uterine 
body is enlarged through pregnancy or tumor formation, may press 
upon the urethra and obstruct the passage of the urine. 

New-growths, particularly fibroids of the uterus, occasionally 

compress the urethra and cause retention of the urine. In a woman 

of thirty-five to fifty years of age who complains of retention of 

urine during the days of premenstrual and menstrual congestion 

it is probable that a uterine fibroid may be found to press on the 

urethra. 

(571) 



572 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM 

3. Obstruction of the urethra, bladder, and ureters by new-growths 
and calculi occupying the interior of these structures. 

4. Spasmodic retention due to a spasm of the urethra. This 
disorder is much rarer in women than in men. It has been improp- 
erly called a spasmodic stricture. 

5. Atony of the bladder due to overdistention and as a complica- 
tion of certain nervous and wasting diseases. 



INDEX. 



ABDOMEN, auscultation of, 64 
in ectopic pregnancy, 150 
in pregnancy, 135 
inspection of, 59 
mensuration of, 64 
palpation of, 60 

in ectopic pregnancy, 161 
percussion of, 63 
Abdominal examination, external, 59 

wall, phantom tumors of, 456 
Abdominovaginal examination, 70 
Abdominovaginorectal examination, 77 
Abortion, diagnosis of, 139 

tubal, 154 
Abscess formation in tubal pregnancy, 
152 
of ovary, 425, 426, 428 
of uterus, 306 
pericaecal, 453 
tubo-ovarian, 426 
Actinomycosis of Fallopian tube, 403 

of ovary, 433 
Acute abdominal affections differenti- 
ated from tubal pregnancy, 169 
Adenocarcinoma uteri, 358 
Adenofibromyoma uteri, 318 
Adhesions, diagnosis of, 462 
Adipocere, 157 
Alcohol as a fixing agent, 97 
Alcoholism, cause of sterility, 46 
Allantoic cyst, 461 

differentiated from ovarian 
tumors, 461 
Amenorrhtxa, 36 
absolute, 36 

catching cold a cause of, 37 
causes of, general, 36 

local, 37 
changes in environment a cause 

of, 37 
debilitating disease a cause of, 36 
diseases of genital organs causing, 

38 
hypoplasia and atrophy causing, 

37 
mental shock and anxiety causing, 

37 
relative, 36 
Ampullar tubal pregnancy, 149 
Amyloid degeneration of uterine fib- 
roids, 323 



Anaemia causing sterility, 45 

uterine hemorrhage, 29 
Anatomy of bladder, 488 

of ovary, 410 

of peritoneum, 470 

of urethra, 488 
Angioma of \Tilva, 253 
Anteflexion differentiated from retro- 
versiofiexion of uterus, 247 

of uterus, 238 
Anteposition of uterus, 215 
Anteversion of uterus, 237 
Apoplexia uteri, 34 
Arteriosclerosis of uterus, 33 
Ascites differentiated from ovarian 
tumors, 456 

free, 456 
Atresia of urethra, 510 

of vagina, 267 

of vulva, 248 
Atrophy of ovary, 414 
congenital, 411 

of uterine fibroids, 322 

of vulva, 248 



BACTERIOLOGICAL examinations 
of the genital tract, 116 
aerogenous infections, 119 
bacillus coli communis, 121, 122 
bacteriology of normal genital 

tract, 116 
diphtheria bacillus, 118 
gonococcus infection, 120, 122 

of vulva and vagina, 118 
infectious granulomata, 121 
pneumococcus of Fraenkel, 121 

infection of ovary, 123 
staphylococcus bacteria, 121 
streptococcus and staphylococcus, 

120, 122 
tubercle bacillius, 118, 123 
typhoid bacillus, 121 
Ballottement, 132 
Bardeen CO2 freezing microtome, 95 
Bartholinean gland, cysts of, 261 
Benign non-infectious peritonitis, 471 
Bicornate uterus, 208 

pregnant, 168 
Bladder, anatomy of, 488 

catheter in ex3,mination of, 493 

(573) 



574 



INDEX 



Bladder, digital examination of, 493 
distended, differentiated from 

ovarian tumors, 455 
examination of, methods of, 492 
catheter and sound, 493 
cystoscopy, 494 
inspection, 493 
Kelly-Pawlik, 494 
Nitze, 494 
palpation, 492 
percussion, 492 
segregator, 508 
urethroscopy, 494 
hemispheres of, 492 
inspection of, 493 
irritable, in pregnancy, 128 
landmarks in, 490 
normal, cvstoscopic appearance of, 

497 
palpation of, 492 
percussion of, 492 
physiology of, 490 
quadrants of, 492 
topography of, 490 
Blasenmole, 173 
Blood anaemia, 113 

primary, 113 
secondary, 114 
bacteriological examinations, 108 
estimation of blood cells, 104 

of haemoglobin, 106 
examinations, 103 
histological examination, 106 
leukocytosis, 110 

inflammatory, 112 
of malignancy, 113 
of pregnancy. 111 
pathological. 111 
post-partum. 111 
morphology of blood cells, 108 
Bozeman's specula, 80 
Broad ligament fibroids of uterus, 
329 



CALCAREOUS degeneration of uter- 
ine fibroids, 322 
Cancerous degeneration of uterine 
fibroids, 324 
ulcers of cer^dx, 305 
Carcinoma, 340 

of cervix, 340, 351, 357, 363 
cauliflower, 342 
differentiated from endocer- 
vicitis, 300 
of corpus uteri, 340, 346, 351, 358 
of Fallopian tube, 404 
infiltrating, of vaginal portion of 

cervix, 342 
of ovary, 466 
squamous-cell, of body of uterus, 

342 
sync3^tiale, 192 
of urethra, 514- 



Carcinoma uteri, classification of, topo- 
graphical, 340 
recurrence in, 368 
of uterus, 340 

cachexia in, 349 
diagnosis of, clinical, 347 
anatomical, 342 
differential, 360 
extension of, 366 
microscopic, 353 
recurrence of, 368 
etiology of, 340 
exploration of uterine cavity 

in, 352 
hemorrhage in, 348 
heredity in, 341 
leucorrhcea in, 348 
pain in, 348 
squamous-cell, 354 
symptoms, miscellaneous, in, 

349 
topographical classification, 
340 
of vagina, 379 

differentiated from decubitus 

ulcers, 281 

from syphilitic ulcers, 281 

from tuberculous ulcers, 

281 

of vaginal portion of cervix, 340, 

342, 349, 353, 360 
of vulva, 258 
Carcinomatous peritonitis, 472 
Caruncle, 513 
Case record, form of, 19 
Catarrh of cervix, 299 
Catarrhal endometritis, 286 
salpingitis, 381 
vaginitis, 273 
Catheter in examining bladder, 493 
Cauliflower carcinoma of cervix, 342 
Celloidin sections, 99 
Cellulitis, pelvic, 479 
acute, 480 
chronic, 481 
classification of, 479 
definition of, 479 
diagnosis of, differential, 483 
differentiated from malignant 
disease of pelvis, 485 
from paratyphlitis, 485 
from pelvic hsematoma, 
485 
peritonitis, 484 
from psoas abscess, 485 
from retrouterine peri- 
metritis, 484 
from subserous fibroid, 
■ 485 
exudate in, consistency of, 
483 
form of, 483 
mobihty of, 483 
position of^ 482 



INDEX 



575 



Cellulitis, pelvic, exudate in, relation 
of, to neighboring or- 
gans, 483 
tenderness of, 483 
Cervical catarrh, 299 
endometritis, 299 
Cervix, carcinoma of, 340, 351, 359, 363 
cauliflower, 342 
differentiated from endo cer- 
vicitis, 363 
vaginal portion of, 340, 342, 
349, 353, 360 
catarrh of, 299 
ectropion of, differentiated from 

endocervicitis, 304 
erosions of, 301 

classification of, 301 
diagnosis of, differential, 303 
follicular, 301 
healing of complete, 303 

incomplete, 303 
papillary, 301 
simple, 301 
fibroids of, 314, 364 

interstitial, 316, 364 
follicular degeneration of, 301 
hemorrhage from, 24 
laceration of, 138 
mucous membrane of, eversion of, 
304, 360 
patch on, 301, 360 
sarcoma of, 372, 362 
technique of excising piece of, for 

microscopic examination, 94 
test excision of, 94 
tuberculosis of, 305 
ulcers of, 305 

cancerous, 305 
decubitus, 305, 360 
syphilitic, 361 
tuberculous, 305, 361 
vaginal portion of, infiltrating car- 
cinoma of, 342 
Chorioepithelioma malignum, 192 
diagnosis of, 193 
etiology of, 193 
following hydatiform mole, 

183, 187 
macroscopic appearance of, 

194 
primary, outside the placental 

site, 196 
of vagina, 196, 282 
Chorion, hydatiform degeneration of, 

173, 
Chorionic villi in hydatiform mole, 174 
Chylous cvsts of mesentery, 461 
Colpitis, 272 

emphysematous, 275 
Conception, conditions essential to, 43 
retained products of, diagnosed by 
curette, 89 
Condylomatous vaginitis, 275 
Confiiiement, date of, 136 



Congestion of ovary, 415 
Connective-tissue tumors of ovary, 447 
Corpus luteum cysts, 429 

uteri, carcinoma of, 340, 346, 351, 
358 
Currier's speculum, 80 
Cusco's speculum, 80 
Cystadenoma pseudomucinosum, 404 
Cystic degeneration of ovary, 420, 

differentiated from ova- 
rian tumors, 452 
mole, 173 

new-formations of Fallopian tube, 
406 
Cystoscope, Nitze, 494 
Cystoscopic appearance of normal blad- 
der, 496 
Cystoscopy, 494 

Cysts, allantoic, differentiated from 
ovarian tumors, 461 
of Bartholinean gland, 261 
chylous, differentiated from ova- 
rian tumors, 461 
of mesentery, 461 
corpus luteum, 355 
dermoid, of Fallopian tube, 404 

of ovary, 443 
echinococcus, differentiated from 

ovarian tumors, 455 
hydatid, of Morgagni, 406 
of hymen, 266 
of labia minora, 262 
ovarian, 433 

degeneration of, malignant, 

466 
differentiated from peritoni- 
tis, 453 
from salpingitis, 398 
fate of, 468 
hemorrhage into, 465 
leakage of, 465 
malignant degeneration of, 

466 
rupture of, 465 
suppuration of, 465 
torsion of pedicle of, 463 
pancreatic, 460 
parovarian, 398, 449 
of pelvis, echinococcus, 455 
sebaceous, of vulva, 261 
simple, of ovary, 429 
tubo-ovarian, 385 

of Fallopian tube, 406 
of vagina, 277, 231 

differentiated from prolapsus 
uteri, 231 
of vulva, 362 

dermoid, 443 



D 



ECIDUA, discharge of, in ectopic 

pregnancy, 146 
of ectopic pregnancy, 162 
removal of, by curette, 89 



576 



INDEX 



Decidiia, serotina, 158 

vera in hydatiform mole, 177 
Decidual endometritis, 288 
Deciduoma malignum, 192 
Decubitus ulcers of cervix, 305 

of vagina, 274 
Degeneration of uterine fibroids, 320 
Dermoid cysts of Fallopian tube, 404 
of ovary, 443 
of vulva, 258 
Descensus ovarii, 412 
Diagnosis of abortion, 139 

anatomical, of carcinoma of uterus 
253 
of pregnancy, 140 
of chorioepithelioma malignum, 

194 
clinical, of carcinoma of uterus, 
347 
of diseases of vagina, 275 
of ectopic pregnancy, 160 
of new-formations of ovary, 

433 
of salpingitis, 393 
differential, of carcinoma of uterus, 
360 
of ectopic pregnancy, 166 
of erosions of cervix, 303 
of peritonitis, 478 
of purulent salpingitis, 396 
early, a plea for, 17 
of life and death of foetus, 135 
microscopic, of cancer of uterus, 
353 
of carcinoma of uterus, 353 
of multiparity, 136 
of sactosalpinx, 395 
of scrapings in endometritis, 299 
of uterine pregnancy, 125 
of variety of ovarian cysts, 467 
Digital examination of bladder, 492 
of internal genitals, 65 
of rectum, 74 
of vagina, 66 
Dilatation of urethra, 510 
Dilating urethral orifice, 508 
Diphtheritic ulcers of vagina, 274 
Dislocations of urethra, 511 
Double uterus, 211 

vagina, 272 
Dropsy of vilH, 173 
Dysmenorrhoea, 39 

inflammatory disease causing, 42 
maldevelopments causing, 41 
malpositions causing, 41 
new-formations causing, 42 
Dysmenorrhceal endometritis, 287 
Dyspareunia, cause of sterility, 46 



ECHINOCOCCUS cyst, differentiated 
from ovarian tumors, 455 
of pelvis, 455 
Ectopic pregnancy, 147 



Ectopic pregnancy, active fetal move- 
ments in, 161 
acute abdominal affections, 

differentiated from, 169 
anatomical changes in, 157 
auscultation of abdomen in, 

161 
bimanual examination in, 165 
classification of, 147, 149 
decidua of, 157 

discharge of, in, 162 
diagnosis of, clinical, 160 
differential, 166 
differentiated from fibro- 

myoma uteri, 169 
from malignant disease 

of pelvis, 169 
from ovarian tumors, 168 
from pelvic exudate, 167 
haematoma and hse- 
matocele, 169 
from pregnancy in a bi- 
cornate uterus, 168 
in a retroverted ute- 
rus, 166 
in a rudimentary 
horn, 168 
etiology of, 147 
genetic reaction in, 148 
retrogressive changes in, 156 
suppuration in, 152 
Ectropion of cervix differentiated from 

endocervicitis, 360 
Elephantiasis of vulva, 253 
Emphysematous vaginae, 275 

colpitis, 275 
Enchondroma of vulva, 258 
Endocervicitis, 299 

differentiated from carcinoma of 
cervix, 304 
from ectropion of cervix, 304 
Endometritis, 284 
acute, 285 
catarrhal, 286 

causing uterine hemorrhage, 31 
cervicalis, 299 
chronic, 286 
classification of, anatomical, 290 

clinical, 286 
decidual, 288 

diagnosed by the curette, 86 
diagnosis of scrapings in, 299 
dysmenorrhoeic, 287 
exfoliative, 289 
forms of macroscopic, 290 

microscopic, 292 
fungous, 291 
glandular, 292 
gonorrhoeal, 288 
hemorrhagic, 286 
hypertrophic, 291 
interstitial, 298 
acute, 298 
chronic, 298 



INDEX 



577 



Endometritis, membranous dysmenor- 
rhoea, 289 
polypoid, 291 
postabortive, 288 
in pregnancy, 288 
pseudodiphtheritic, 291 
puerperal, 288 
senile, 289 

acute, 298 
tuberculous, 287 
ulcerative, 291 

(villous, 291 
Endothelioma ovarii, 449 
uteri, 369 
of vagina, 383 
Epispadias, 249 

Epithelial new-formations of ovary, 434 
Erosions. See Endocervicitis, 301 

tof cervix, 301, 306 
classification of, 301 
diagnosis of, differential, 301 
foUicular, 301, 362 
healing of, 303 
complete, 303 
incomplete, 303 
papillary, 301 
simple, 301 
Erysipelatous vulvitis, 252 
Eversion of mucous membrane of cer- 
vix, 304, 360 
Examinations of the blood, 103 
Examining table, Schmidt, 57 
Exfoliative endometritis, 145, 289 
Extrauterine pregnancy, 147 
, Exudates, parametric, 481 

differentiated from salpingi- 
tis, 397 
paratyphlitic, 484 
perimetric, serous, 476 
peritoneal, 484 



F 



ALLOPIAN tube, actinomycosis of, 

403 
anomalies in structure of, 378 
carcinoma of, 404 
changes in position of, 378 
circulatory disturbances of, 

378 
cystic new-formations of, 406 
dermoid cysts of, 404 
development of, anomalies in, 

378 
examination of, methods of, 

377 
fibroma of, 404 
fibromyxoma cy.stoma of the 

fimbriae of, 404 
gonorrhoeal infection of, 380 
hsemato salpinx of, 386 
hydrosalpinx of, 384 
infectious granuloma of, 398 
inflammations of, 381 
lipoma of, 404 

37 



Fallopian tube in menstruation, 28 
myoma of, 404 
new-formations of, 403 
papilloma of, 403 
parasites of, 403 
polyps of, 403 
pyosalpinx of, 392 
sactosalpinx of, contents of, 
396 
diagnosis of, 395 
salpingitis of, catarrhal, 381 
chronic, 382 
diagnosis of, clinical, 
387 
classification of, 381 
purulent, diagnosis of, 
clinical, 393 
diagnosis of, differ- 
ential, 396 
tuberculous, 398 
sarcoma of, 404 
syphilis of, 402 
tubo-ovarian cysts of, 385 
tumors of, 403 
Fibroids, cardiopathv of, 338 
of cervix, 316, 330, 362 
imperil life by, 335 
interstitial, 316 

of cervix, 316, 362 
of uterus, 308 
intraligamentary, of uterus, 329 
intramural, of uterus, 316 
latent, 316 
retrouterine, 247 

differentiated from retrover- 
sioflexion of uterus, 247 
submucous, 314 
subserous, 316 

differentiated from pelvic cel- 
lulitis, 484 
from salpingitis, 397 
uterine, amvloid degeneration of, 
323 
atrophy of, 322 
calcareous degeneration of, 

322 
cancerous degeneration of, 

324 
clinical characteristics of, 325 
degeneration of, 320 
fatty degeneration of, 322 
gangrene of, 323 
hemorrhage in, 336 
myxomatous degeneration of, 

323 
pressure and traction from, 
326 
of uterus, 308 

differentiated from chronic 
metritis, 332 
from hsematocele, 335 
from ha?matoma, 335 
from uterine pregnancy, 
332 



578 



INDEX 



Fibroids of uterus, submucous, 314 
subserous, 316 
suppuration of, 323 
telangiectatic, 324 
Fibroma of Fallopian tube, 404 
of ovary, 447 
of urethra, 514 
of vulva, 258 
Fibromyoma, sarcomatous, degenera- 
tion of, early recognition of, 324 
atrophy of, 322 
changes in endometrium, 324 
characteristics of, clinical, 325 
degeneration of, 320 
amyloid, 323 
calcareous, 322 
cancerous, 324 
fatty, 322 
myxomatous, 323 
sarcomatous, 324 
diagnosis of, anatomical, 310 
clinical, 326 
differential, 332 
microscopic, 318 
differentiated from ectopic preg- 

nancv, 169 
etiology of, 308 
gangrene of, 323 
hemorrhage in, 336 
histogenesis of, 310 
intraligamentary, 329 
objective signs of, 328 
palpation and adnexse and round 

ligament in, 330 
pressure and traction from, 326 
suppuration of, 323 
telangiectatic, 324 
of vagina, 279 
Fibromvxoma cystoma of the fimbria?, 

404 
Fissures, congenital, of vulva, 249 
Fistulse of urethra, 514 
Fixing of specimens, 95 
Fetal heart tones, 133 
movements, 131 

active, in ectopic pregnancy, 
161 
souffle, 133 
uterus, 204 
Foetus, life and death of, diagnosis of, 

135 
Follicular degeneration of cervix, 301, 
362 
erosions, 301, 362 

of cervix, 301, 362 
Fungous endometritis, 291 
Furunculosis of vulva, 251 



GALL-BLADDER, distended, 383 
differentiated from ovarian 
tumors, 461 
Gangrene of uterine fibroids, 323 
of vulva, 253 



Genital organs, normal secretions of, 

53 
Genitals, external, examination of, 55 

internal, digital examination of, 
65 
Gestation, subperitoneoabdominal, 150 
Glands of pregnancy, 128 
Glandular endometritis, 292 
Gonorrhoeal endometritis, 287 

infection of Fallopian tube, 381 

peritonitis, 471 
Graafian follicles, 410 
Granuloma, infectious, of Fallopian 

tube, 398 
Granulomata, infectious, of ovary, 431 



H HEMATOCELE differentiated from 
fibroids of uterus, 335 
pelvic, 169 
retrouterine, 247 

differentiated from peritonitis, 
478 
Haematocolpos from atresia vaginoo, 

267, 268, 269 
Haimatoma, 169, 335 

differentiated from fibroids of ute- 
rus, 335 
of the ovary, 416 

differentiated from pelvic cel- 
Mitis, 484 
retrouterine, 247, 478 
of vulva, 253 
Hsematometra from atresia vaginae, 

271 
Hsematosalpinx, 387 

from atresia vaginse, 387 
Hsematotrachelos from atresia vaginse, 

269 
Hardening and embedding in celloidin, 
97 
in paraffin, 98 
Hemorrhage in carcinoma of uterus, 
348 
caused by the curette, 90 

by sound, 87 
during pregnancy, 137 
in fibromyoma uteri, 326 
from genital tract, 24 
intraperitoneal, 162 
into ovarian cysts, 465 
uterine anaemia, a cause of, 29 
endometritis causing, 31 
local causes of, 30 
passive congestion causing, 30 
plethora causing, 29 
purpuric conditions causing, 

30 
specific infectious diseases 

causing, 30 
subinvolution causing, 30 
systemic causes of, 29 
in uterine fibroids, 320 
from vagina, 24 



INDEX 



579 



Hemorrhage from vulva, 24 
Hemorrhagic endometritis, 31, 286 

metritis of menopause, 33 
Hermaphroditism, 205 
Hernia of ovary, 413 

of uterus, 247 
Hydatid mole, 173 
Hydatids, uterine, 173 
Hydatiform degeneration of chorion, 
173 
mole, chorio epithelioma malig- 
num following, 182 
chorionic villi in, 177 
decidua seroiina in, 177 

vera in, 177 
degeneration of, malignant, 

182 
diagnosis of, 186 
examination of, microscopic, 

177 
history of, 173 
syncytioma malignum follow- 
ing, 182 
Hydronephrosis, 551 

differentiated from ovarian tu- 
mors, 461 
Hydrops tubse profluens, 385 
Hydrosalpinx, 384 

Hymen, 264 tl' 

cysts of, 266 
rupture of, in labor, 264 
Hypertrophic endometritis, 291 
Hypertrophy, congenital, of ovary, 414 
of ovary, 414 
of vulva, 249 
Hypoplasia and atrophy causing amen- 

orrhoea, 37 
Hypospadias, 249 
of vulva, 249 
Hysterocele, 247 



INFANTII;E vulva, 248 
Infectious granulomata of Fal- 
lopian tube, 398 
granulomata of ovary, 431 
Infiltrating carcinoma of vaginal por- 
tion of cervix, 342 
Inflammations of Fallopian tube, 379 
of ovary, 419 
of urethra, 512 
Inflammatory diseases causing dys- 
menorrhcea, 42 
sterility, 48 
Infundibular tubal pregnancy, 156 
Interstitial endometritis, 298 
acute, 298 
chronic, 298 
fibroid of cervix, 316 

of uterus, 308 
tubal pregnancy, 147 
Interureteric ligament, 491 
Intraligamentary development of ova- 
rian tumors, 462 



Intraligamentary fibroids of uterus, 

329 
Intramural fibroids of uterus, 316 
Intraperitoneal hemorrhage, 162 
Inversion of the uterus, 231 

differentiated from partially 
divided uterus with a 
depression in the fun- 
dus, 236 
from pedunculated fib- 
roid or polyp lying 
within the vagina, 236 
from prolapsus uteri, 237 
from submucous fibroid 
lying within the cavity 
of the uterus, 236 
from submucous fibroid 
with partial inversion, 
237 



KELLY-PAWLIK method of cys- 
toscopy, 494 
Kidney, diagnosis of, 546 
calculi, 564 
enlargement of, 550 

hydronephrosis, 551 
new-formations, 558 
perinephric abscess, 554 
pyonephrosis, 552 
methods of examination, 546 
movable kidney, 548 
renal calculi, 564 
topography, 546 
tuberculosis, 556 
Knee-chest position, 68 
Kraurosis vulvae, 256 



LABIA minora, cysts of, 262 
Labor, spurious, 162 
Lateroposition of uterus, 217 
Leprosy of ovary, 433 
Leucorrhoea, 53 

in cancer of uterus, 55, 348 
in infants, 53 
in old women, 55 
in pregnancy, 130 
in sexual maturity, 54 
in virgins, 54 
Lipoma of Fallopian tube, 404 

of vulva, 258 
Lithopedion, 156 
Lithotomy position, 68 
Liver, tumors of, 460 

differentiated from ovarian 
tumors, 460 



MALDEVELOPMENTS causing 
dysmenorrhcea, 41 
sterility, 46 
of ovary, 410 
of vagina, 267 



580 



INDEX 



Malformations causing sterility, 46 
congenital, of urethra, 510 
of urethra, acquired, 510 
of uterus, 203 

accessorius, 211 
bicornis, 208 

unicellis, 208 
deficiens, 203 
didelphys (uterus duplex, 

uterus separatus), 211 
foetalis, 204 
membranaceous, 204 
rudimentarius, 204 
septus (bilocularis), 208 

duplex, 211 
unicornis, 206 
of vagina, 267 
Malignant growth diagnosed bv the cu- 
rette, 89 
Malpositions causing dysmenorrhoea,4] 
sterility, 46 
of uterus, 212 

anteflexion, 238 
anteposition, 215 
anteversion, 237 
clevatio uteri, 219 
hernia, 247 
inversion, 231 
lateroposition, 217 
pathological fixation, 215 

mobility, 215 
primary descent, 220 
prolapsus, 220 
retroposition, 216 
retro versioflexion, 240 
secondary descent, 220 
torsion, 220 
Mammary glands, changes of, in preg- 
nancy, 128 
changes in, in tubal preg- 
nancy, 161 
Marriage of near relatives a cause of 

sterility, 45 
Membranaceous uterus, 204 
Menopause, 49 

clinical manifestations of, 44 
dela^-ed, 50 
effect of climate on, 51 
heredity on, 51 
race on, 51 
social state on, 51 
hemorrhagic, metritis of, 33 
premature, 50 
Menorrhagia, 29 
Menses, retention of, 37 
Menstruation, 25 
anatomy of, 26 
effects of ovariotomy on, 38 
Fallopian tube in, 28 
menstrual molimina, 38 
pain during, 39 
physiological absence of, 36 
in tubal pregnancy, 160 
Mesentery, chjdous cysts of, 383 



Metastasis in carcinoma uteri, 303 
Metritis, chronic, 306 

differentiated from fibroids of 
uterus, 332 
hemorrhagic, of menopause, 33 
Metrorrhagia, 29 
Miscarriages, number of children and, 

23 
Mole, cystic, 173 

formation in tubal pregnancy, 156 
hydatid, 173 

hydatiform, chorioepithelioma ma- 
lignum following, 182 
chorionic villi in, 177 
decidua vera in, 177 
history of, 173 
Morning sickness, 127 

in tubal pregnancy, 160 
Mucous patch on cervix, 301 

polyps, 300 
Multiparity, diagnosis of, 137 
Mummification, 156 
Myoma of Fallopian tube, 404 
ovarii, 448 
uteri, 308 
Myxoma chorii, 173 
Myxomatous degeneration of uterine 
■fibroids, 323 



NARCOSIS, examination under, 74 
Nervous phenomena in preg- 
nancy, 128 
in tubal pregnancy, 160 
Neuroma of vulva, 258 
Nitze cystoscope, 494 



OBESITY, 461 
cause of sterility, 45 
(Edema of vulva, 253 
Omentum, fatty tumors of, 455 
Oophoritis, 419 

Ovarian cyst, degeneration of, malig- 
nant, 466 
diagnosis of variety of, 467 
differentiated from peritoni- 
tis, 453 
from salpingitis, 398 
exploratory puncture and in- 
cision of, 468 
fate of, 468 
hemorrhage in, 465 
leakage of, 465 
malignant degeneration of, 

466 
rupture of, 465 
suppuration of, 465 
torsion of pedicle of, 463 
tumors, 433 

bilateral, 462 

complicating pregnancy, 467 
development of, intraliga- 
mentary, 462 



INDEX 



581 



Ovarian tumors differentiated from 
allantoic cysts, 461 
from ascites, 456 
from chylous cysts, 461 
from cystic degeneration 

of ovaries, 452 
from distended bladder, 

455 
from distended gall-blad- 
der, 461 
from echinococcus cyst, 

455 
from ectopic pregnancy, 

455 
from fatty tumors, 461 
from hydronephrosis, 461 
from pancreatic cysts, 

457, 460 
from parovarian cvsts, 

455 
from phantom tumors, 

456 
from splenic tumors, 460 
from tumors of liver, 460 
fate of, 468 

intraligamentary, develop- 
ment of, 462 
Ovariotomy, effect on menstruation, 38 
Ovaritis, 419 
acute, 419 
chronic, 420 

diagnosis of, clinical, 426 
differentiated from congestion of 
ovary, 429 
from new-growth of ovary, 

429 
from parametric exudates,429 
from perityphlitis, 429 
salpingitis, 429 
tuberculous, 431 
Ovary, abscess of, 428 
acute, 425 
chronic, 426 
absence of, 410 
actinomycosis of, 433 
anatomy of, 407 
atrophy of, 411 

congenital, 411 
carcinoma of, 441 
changes in position of, 412 
circulatory disturbances of, 415 
congestion of, 415 

differentiated from ovaritis, 
429 
corpus luteum cysts of, 429 
cystic degeneration of, 420 

differentiated from ova- 
rian tumors, 452 
cysts of, dermoid, 443 

simple, 429 
degeneration of, cystic, 420 
development of, anomalies in, 410 
endothelioma of, 449 
examination of, methods of, 409 ' 



Ovary, fibroma of, 447 

granulomata of, infectious, 431 
haematoma of, 416 
hernia of, 413 
histology of, 408 
hypertrophy of, 414 
congenital, 414 
inflammation of, 419 
leprosy of, 433 
maldevelopments of, 410 
myoma of, 448 
new-formations of, 433 

clinical diagnosis of, 451 

epithelial, 434 
new-growths of, 433 

differentiated from ova- 
ritis, 452 
parasites of, 415 
sarcoma of, 448 
supernumerary, 411 
syphilis of, 433 
torsion of pedicle of, 463 
tuberculosis of, 431 
tumors of, 433 
adherent, 462 
connective tissue, 447 



PANCREATIC cysts, 460 
differentiated from ovarian 
tumors, 460 
Papillary erosions, 301 
Papilloma of Fallopian tube, 403 
Paraffin sections, 98 
Parametric exudates, 484 

differentiated from ovaritis, 
429 
from salpingitis, 397 
Parametritis. See Pelvic cellulitis, 479, 
484 
acute, 480 
chronic, 481 
retrouterine, 484 
Parasites of Fallopian tube, 403 
Paratyphlitic exudate, 484 
Paratyphlitis differentiated from pel- 
vic cellulitis, 484 
Paravaginitis, 276 
Parovarian cysts, 449 

differentiated from ovarian 
tumors, 455 
from salpingitis, 397 
Pawlik method of cystoscopy, 494 
Pedunculated fibroids and polyps ly- 
ing within the vagina, 321 
Pelvic cellulitis, 479 
acute, 480 
chronic, 481 
classification of, 479 
definition of, 479 
diagnosis of, differential, 483 
differentiated from malignant 
disease of pelvis, 485 
from paratyphlitis, 484 



582 



INDEX 



Pelvic cellulitis differentiated from 
pelvic haematoma, 
484 
peritonitis, 483 
from psoas abscess, 485 
from retrouterine peri- 
metritis, 484 
from subserous fibroid, 
484 
, exudate in, consistency of, 483 
form of, 482 
mobility of, 482 
position of, 481 
relation of, to neighbor- 
ing organs, 483 
tenderness of, 483 
exudate, 481 

differentiated from ectopic 
pregnancy, 167 
hsematocele differentiated from 

ectopic pregnancy, 169 
haematoma, 484 

differentiated from pelvic cel- 
lulitis, 484 
and hirmatocele, 169 
inflammation, acute and subacute, 
a contraindication to cu- 
rettage, 90 
caused by the sound, 87 
peritonitis, 470 
acute, 475 

adhesions in, peritoneal, 476 
chronic, 475 
definition of, 473 
diagnosis of, clinical, 477 

differential, 478 
differentiated from pelvic cel- 
lulitis, 483 
etiology of, 474 
exudates in, peritoneal, 476 
Pelvimetry, 78 

Pelvis, cysts of, echinococcus, 455 
malignant disease of, 366 

differentiated from ec- 
topic pregnancy, 169 
Pericsecal abscess, 396, 484 
Perimetric exudates, serous, 476 

retrouterine, differentiated 
from pelvic cellulitis, 484 
Perineum, rupture of, in labor, 221 
Periovaritis, tuberculous, 432 
Peritoneal adhesions, 476 

exudates, 476 
Peritoneum, anatomy of, 470 
Peritonitis, 470 

benign, non-infectious, 471 
carcinomatous, 471 
diagnosis of, differential, 478 
differentiated from ovarian cyst, 
453 
from retroflexed gravid ute- 
rus, 478 
from retrouterine haemato- 
cele, 478 



Peritonitis, general, 471 
gonorrhceal, 471 
pelvic, 473 

acute, 475 

adhesions in, peritoneal, 476 

chronic, 475 

definition of, 473 

diagnosis of, clinical, 477 

differential, 478 
differentiated from pelvic 

cellulitis, 483 
etiology of, 474 
exudates in, peritoneal, 476 
putrid, saprophytic, 471 
retrouterine, 484 
septic, 471 
tuberculous, 471 
Perityphlitis, 453 

differentiated from ovaritis, 453 
Placenta praevia, 33 

premature detachment of, 33 
Placental souffle, 133 

tissue retained, 364 
Plethora causing uterine hemorrhage, 

29 
Polypoid endometritis, 291 
Polyps of Fallopian tube, 403 
Postabortive endometritis, 288 
Pregnancy, auscultation of abdomen 
in, 133 
in bicornate uterus, 168 
in a bicornate uterus differen- 
tiated from ectopic pregnancy, 
168 
changes in mammary glands in, 

128 
complicated by ovarian tumors, 

467 
complicating tubal or ovarian 

swelling, 467 
contraindications to curettage 

after, 90 
diagnosis of, anatomical, 140 
discoloration of vagina in, 128 
ectopic, 147 

active fetal movements in, 

161 
anatomical changes in, 157 
auscultation of abdomen in, 

161 
bimanual examination in, 165 
classification of, 149 
decidua of, 137, 146 

discharge of, in, 162 
diagnosis of, clinical, 160 

differential, 166 
differentiated from fibromy- 
oma uteri, 169 
from malignant disease 

of pelvis, 169 
from ovarian tumors, 168 
from pelvic exudate, 167 
haematoma and hae- 
matocele, 169 



INDEX 



583 



Pregnancy, ectopic, differentiated from 
pregnancy in a 
bicornate uterus, 
168 
in a retroverted ute- 
rus, 166 
in a rudimentary 
horn, 168 
from uterine pregnancy 
complicated with tu- 
bal or ovarian swelling, 
166 
discoloration of vagina in, 161 
etiology of, 147 
genetic reaction in, 148 
palpation of abdomen in, 161 
retrogressive changes in, 166 
suppuration in, 156 
endometritis in, 288 
extrauterine, 147 
glands of, 142 
hemorrhage during, 137 
interstitial tubal, 156 
irritable bladder in, 128 
leucorrhoea in, 130 
multiple diagnosis of, 137 
nervous phenomena in, 128 
ovarian tumors complicating, 168 
position of uterus in, 135 
in retroverted uterus, 166 ' 
retroverted uterus complicating, 

166 
in a retroverted uterus differen- 
tiated from ectopic pregnancy, 
166 
in a rudimentary horn differen- 
tiated from ectopic pregnancy, 
168 
tubal, 147 

abscess formation in, 152 

ampullar, 149 

changes in mammary glands 

in, 161 
infundibular, 156 
menstruation in, 160 
mole formation in, 155 
morning sickness in, 160 
nervous phenomena in, 160 
pain in, 160 
uterine, 332 

complicated with tubal and 

ovarian swellings, 166 
diagnosis of, 125 
differentiated from fibroids of 
uterus, 332 
Prolapse of urethra, 511 
of uterus, 225 
of vagina, 224 
Prolapsus uteri, 225 

with atresia, 231 
differentiated from inversion 
of uterus, 237 
from cyst of vagina, 231 
Pruritus, 263 



Pseudodiphtheritic endometritis, 291 
Psoas abscess, 485 

differentiated from pelvic cel- 
Mitis, 485 
Puerperal endometritis, 288 
ulcers of vagina, 274 
vaginitis, 274 
vulvitis, 252 
Purpuric conditions causing uterine 

hemorrhage, 29 
Purulent salpingitis, 389 
Pus tube, 392 

Putrid saprophytic peritonitis, 471 
Pyosalpinx, 392 



/QUADRANTS of bladder, 492 

EECTUM, abdominorectal exami- 
nation of, 76 
digital examination of, 74 
traction on uterus in examina- 
tion of, 76 
Renal calculi, 564 
Retroposition of uterus, 216 

differentiated from retrover- 
sioflexion of uterus, 247 
hsematocele, 335 
haematoma and hsematocele, 247, 

478 
parametritis, 484 
perimetritis differentiated from 

pelvic cellulitis, 484 
peritonitis, 484 
Retroversioflexion of uterus, 240 

differentiated from anteflex- 
ion, 247 
from retrouterine fib- 
roids, 247 
from swellings of tubes 
and ovaries, 246 
Retroverted uterus complicating preg- 
nancy, 166 
Rodent ulcers of vulva, 262 
Rudimentary uterus, 204 

SACTOSALPINX, contents of, 396 
diagnosis of, 395 
of Fallopian tube, contents of, 
396 
diagnosis of, 395 
purulenta, 394 
Salpingitis, 381 
catarrhal, 381 
acute, 382 
chronic, 382 
classification of, 381 
differentiated from appendicitis, 
396 
from new-formation of tubes, 

398 
from ovarian cysts, 398 



584 



INDBX 



Salpingitis differentiated from ovarian 
tumors, 398 
from parametric exudates, 

397 
from parovarian cysts, 398 
from subserous fibroids, 397 
of Fallopian tube, diagnosis of, 

clinical, 387 
isthmica nodosa, 383 
purulent, of Fallopian tube, diag- 
nosis of, clin- 
ical, 393 
differential, 396 
tuberculous, 398 

of Fallopian tube, 398 
Sarcoma of body of uterus, 374 
of cervix, 373 

of uterus, 371 

vaginal portion, 372 
of Fallopian tube, 404 
ovarii, 448 
of urethra, 514 
of uterus, 371 

diagnosis of, anatomical, 372 
clinical, 375 
microscopic, 374 
etiolog}' of, 371 
of vagina, 282 
of vulva, 261 
Sarcoma-choriocellulare, 192 
Sarcomatous degeneration of a fibro- 

myoma, early recognition of, 375 
Sebaceous cysts of vulva, 258 
Secondary descent and prolapse of 

uterus, 225 
Segregator, 508 
Senile endometritis, 289 

acute, 298 
Septic peritonitis, 471 
Sexual excess a cause of sterility, 46 
incompatibility a cause of sterility, 

46 
instinct, its influence upon steril- 
ity, 46 
Simons' speculum, 80 
Sims' duck-bill speculum, 79 
position, 79 
vaginal depressor, 79 
Soft chancre, 252 
Souffle, fetal 133 

placental, 133 
Sound in examining urethra and blad- 
der, 493 
use of, in uterine fibroids, 330 
Specimens, mounting of, method of, 99 

staining of, method of, 99 
Speculum, urethral, introduction of, 
493 
vaginal, 79 

Bozeman's, 80 
Curco's, 80 
Currier's, 79 
Pean's, 79 
Simons', 79 



Speculum, vaginal, Sims' duck-bill, 70 

tubular, 79 
Splenic tumors, 460 
Squamous-cell carcinoma of uterus, 342 
Sterility, 43 

alcoholism a cause of, 46 

anaemia a cause of, 45 

causes of, 45 

dyspareunia a cause of, 46 

inflammatory diseases causing, 48 

influence of sexual instinct on, 46 

maldevelopment causing, 46 

malformations causing, 46 

malpositions causing, 47 

new-formations causing, 49 

obesity a cause of, 45 

primary, 44 

secondary, 44 

sexual excess a cause of, 46 

incompatibility a cause of, 46 

traumatisms causing, 48 
Streptococcus infection of Fallopian 

tube, 396 
Striae gravidarum, 137 
Stricture of urethra, 511 
Subinvolution causing uterine hemor- 
rhage, 30 
Submucous fibroids, 314 

partial inversion, 237 
of uterus, 314 

and interstitial fibroids, 316 
Subperitoneal fibroids of uterus, 316 
Subperitoneoabdominal gestation, 150 
Subserous fibroid, 316 

fibroids of uterus, 316 
Supernumerary ovary, 341 
Syncytioma malignum following hy- 
datiform mole, 182 

of vagina, 282 
Syphilis of cervix, 361 

of Fallopian tube, 402 

of ovary, 433 
Syphilitic ulcers differentiated from 
carcinoma of vagina, 281 
of vagina, 281, 274 

vulvitis, 263 



TELANGIECTATIC fibroids of ute- 
rus, 324 
Torsion of pedicle of ovarian cysts, 463 

of uterus, 221 
Traumatisms causing sterility, 48 
Trigone, 490 
Tubal abortion, 154 
pregnancy, 147 

abscess formation in, 152 
acute abdominal affections, 

differentiated from, 169 
ampullar, 149 
infundibular, 156 
interstitial, 156 
menstruation in, 160 
mole formation in, 155 



INDEX 



685 



Tubal pregnancy, morning sickness in, 
160 ■ 
nervous phenomena in, 160 
pain in, 160 
Tuberculosis of cervix, 361 

of ovary, 431 
Tuberculous endometritis, 287 
ovaritis, 431 
periovaritis, 431 
salpingitis, 398 

ulcers differentiated from carcino- 
ma of vagina, 281 
of cervix, 361 
of vagina, 281 
of vulva, 263 
vaginitis, 281 
vulvitis, 263 
Tuboperitoneal gestation, 152 
Tumors, adherent, of ovary, 462 
connective tissue, of ovary, 447 
of Fallopian tube, 403 
fatty, differentiated from ovarian 
tumors, 461 
of omentum, 455 
of liver, 460 

differentiated from ovarian 
tumors, 460 
of omentum, 455 
ovarian, 433 

bilateral, 384 

complicating pregnancy, 467 

development of, intraliga- 

mentary, 462 
differentiated from allantoic 
cysts, 461 
from ascites, 456 
from chylous cysts, 461 
from cystic degeneration 

of ovaries, 452 
from distended bladder, 

455 
from distended gall-blad- 
der, 461 
from echinococcus cyst, 

455 
from ectopic pregnancy, 

455 
from fatty tumors, 461 
from hydronephrosis, 461 
from pancreatic cysts, 

460 
from parovarian cysts, 

455 
from phantom tumors, 

456 
from splenic tumors, 460 
from tumors of liver, 
460 
fate of, 468 

intraligamentary development 
of, 462 
of ovary, 433 

adherent, 462 
phantom, of abdominal wall, 456 



Tumors, phantom, differentiated from 
ovarian tumors, 456 
splenic, 460 

differentiated from ovarian 
tumors, 460 
of urethra, 513 
of vulva, 258 



ULCERATIVE endometritis, 291 
vaginitis, 274 
Ulcers, cancerous, of cervix, 305 
of cervix, 305 

tuberculous, 305, 361 
decubitus, 305, 360 
syphilitic, of cervix, 361 

differentiated from carcinoma 

of vagina, 281 
of vagina, 281, 274 
tuberculous, 281 

differentiated from carcinoma 
of vagina, 281, 274 
of vagina, decubitus, 281, 274 
diphtheritic, 274 
puerperal, 274 
tuberculous, 274 
of vulva, 217 
rodent, 262 
syphilitic, 263 
tuberculous, 263 
Ulcus moUe of vulva, 252 
Unicornate uterus, 206 
Ureter, 531 

anatomy of, 531 
catheterization of, 533 
congenital anomalies, 538 
hydroureter, 543 
methods of examination, 532 
obstruction of, 541 
calculus, 542 
stricture, 543 
physiology, 532 
ureteral fistula, 544 
Ureteral orifices, 490 
Ureteritis, 539 
Urethra, absence of, 510 
anatomy of, 488 
atresia of, 510 
carcinoma of, 514 
dilatation of, 508, 510 
dislocation of, 510, 511 
displacements of, 510 
examination of, methods of, 492 
catheter and sound, 493 
cystoscopy, 494 
inspection, 493 
Kelly-Pawlik, 494 
Nitze, 494 
palpation, 492 
percussion, 492 
segregator, 508 
urethroscopy, 494 
iibroma of, 514 
fistulas of, 514 



586 



INDEX 



Urethra, foreign bodies in, 514 
inflammation of, 512 
inspection of, 508 
malformations of, 510 
acquired, 510 
congenital, 510 
new-growths of, 513 
palpation of, 492 
partial or complete absence of, 

510 
physiology of, 488 
prolapse of, 511 
sarcoma of, 514 
stricture of, 511 
tumors of, 513 
Urethral caruncle, 211 
fistulae, 514 

speculum, introduction of, 494, 
508 
Urethritis, 512 
acute, 512 
chronic, 513 
Urethroscopy, 508 
Uterine cavity exposed, 100 

contractions, intermittent, 134 
curette, 88 

contraindications for, 90 
dangers involved in, 90 
in diagnosis, 88 
dilators, 83 

Ellinger's, 83 
Goodell's, 83 
Hegar's, 83 
displacements, diagnosis of adhe- 
sions causing, 245 
fibroids, 308 

amyloid degenerations of, 

323 
atrophy of, 322 
calcareous degeneration of, 

322 
cancerous degeneration of, 

324 
clinical characteristics of, 325 
degeneration of, 320 
fatty degeneration of, 322 
gangrene of, 323 
hemorrhage in, 336 
myxomatous degeneration of, 

'323 
pressure and traction from, 
326 
hemorrhage, anaemia a cause of, 
29 
endometritis causing, 31 
passive congestion causing, 30 
plethora causing, 29 
purpuric conditions causing, 

30 
specific infectious diseases 

causing, 30 
subinvolution causing, 30 
hydatids, 173 
pregnancy, 332 



Uterine pregnancy, complicated with 
a tubal and ovarian swell- 
ing, 166 
diagnosis of, 125 
differentiated from fibroids of 
uterus, 332 
segment, lower, softening and 
compressibility in pregnancy, 
130 
sound, 84 

dangers involved in the use 

of, 87 
indications for the use of, 85 
preliminary procedures, 85 
tissue, removal of, for diagnostic 
purposes, 93 
Uterus, abscess of, 306 
absence of, 203 
accessory, 211 
anteflexion of, 238 
anteposition of, 215 
anteversion of, 237 
arteriosclerosis of, 33 
body of, sarcoma of, 374 

squamous-cell carcinoma of, 
358 
broad ligament fibroids of, 329 
cancer of, leucorrhoja in, 348 
carcinoma of, 340 

bimanual palpation in, 352 
cachexia in, 349 
diagnosis of, anatomical, 342 
clinical, 347 
differential, 360 
extension of, 345, 366 
microscopic, 353 
recurrence of, 368 
etiology of, 340 
exploration of uterine cavity 

in, 352 
extension of, 345, 366 
hemorrhage in, 348 
heredity in, 341 
leucorrhcea in, 348 
pain in, 348 
squamous-cell, 342 
symptoms, miscellaneous in, 

349 
topographical classification, 
340 
cervix of, sarcoma of, 373 

vaginal portion, sarcoma of, 
372 
descent of, 220 
double, 211 
elevation of, 219 
endothelioma of, 396 
fibroids of, 308 

differentiated from chronic 
metritis, 332 
from hsematocele, 335 
from hsematoma, 335 
from uterine pregnancy, 
332 



INDEX 



587 



Uterus, fibroids of, interstitial, 316 
intraligamentary, 329 
intramural, 316 
submucous, 314 
subperitoneal, 316 
subserous, 316 
suppuration of, 323 
telangiectatic, 324 
fixation of, pathological, 215 
hemorrhage from, 29 
hernia of, 247 

inspection of, after removal, 100 
inversion of, 231 

differentiated from prolapsus 
uteri, 237 
lateroposition of, 217 
malformation of, 203 
malposition of, 212 
membranes expelled from, 144 
membranous, 204 
mobility of, pathological, 215 
perforation of, by curette, 90 

by sound, 87 
position of, in pregnancy, 135 
primary descent and prolapse of, 

225 
prolapse of, 220 
retroposition of, 216 
retroversioflexion of, 240 

differentiated from anteflex- 
ion, 247 
from retrouterine fibroid 

247 
from swellings of tubes 
and ovaries, 240 
rudimentary, 163 
sarcoma of, 371 

diagnosis of, anatomical, 372 
clinical, 375 
microscopic, 374 
etiology of, 371 
test curettage of, 94 
torsion of, 220 



VAGINA, absence of, 267 
atresia of, 267 
carcinoma of, 279 
chorioepithelioma malignum of, 

282 
cysts of, 277, 231 

differentiated from prolapsus 
uteri, 231 
decubitus ulcers of, 274 
descent of, 224 
diagnosis, clinical, of diseases of, 

275 
digital examination of, 66 
discoloration of, in ectopic preg- 
nancy, 161 
in pregnancy, 128 
displacement of, 224 
double, 272 
emphysematous, 275 



Vagina, endothelioma of, 283 
fibroma of, 279 
haematocolpos of, 270 
hspmatometra of, 270 
haematosalpinx of, 270 
hemorrhage from, 24 
maldevelopments of, 267 
malformations of, 267 
new-formations of, 277 
prolapse of, 224 
sarcoma of, 282 
stenosis of, 267 
syncytioma of, 282 
ulcers of, decubitus, 281 

diphtheritic, 274 

puerperal, 274 

syphihtic, 274, 281 

tuberculous, 274, 281 
Vaginal examination, choice of hand in 
68 

combined, 68 
Vaginitis, 272 

catarrhal, 273 
condylomatous, 275 
puerperal, 274 
tuberculous, 274 
ulcerative, 274 
ViUi, dropsy of, 173 
Villous endometritis, 291 
Vulva, absence of, 248 
angioma of, 253 
atresia of, 248 
atrophy of, 256 
cancer of, 258 
carcinoma of, 258 
circulatory disturbances of, 253 
condylomata acuminata of, 253 
congenital fissures of, 249 
cysts of, 258 

dermoid, 258 
development of, anomalies in, 

247 
double, 247 
elephantiasis of, 255 
enchondroma of, 258 
epispadias of, 249 
fibroma of, 258 
fissures of, congenital, 247 
furunculosis of, 251 
gangrene of, 253 
hsematoma of, 253 
hemorrhage from, 24 
hypertrophy of, 253 
infantile type of, 247 
new-formations of, 258 
oedema, 253 
hypertrophy of, 249 
hypospadias of, 249 
infantile types of, 248 
lipoma of, 258 
neuroma of, 258 
new-formations of, 258 
oedema of, 253 
sarcoma of, 258 



r 



588 

Vulva, sebaceous cysts of, 258 
tumors of, 258 
ulcers of, 262 
rodent, 262 
tuberculous, 281 
ulcus molle of, 252 
Vulvitis, 250 

erysipelatous, 251 



INDEX 



Vulvitis furunculosis, 251 
puerperal, 252 
syphilitic, 262 
tuberculous, 252 






z 



ENKER'S fluid, 96 



,^''**-/0' 



